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intbt€itvoi&tto^oxk 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


Reference  Library 

Given  by 


THE  FAIRCHILD  PREPARATIONS 

—  or  — 

IK  PORE  DIGESTIVE  FERMENTS, 

Active,  Permanent  and  Reliable. 


TRYPSIN 

(fairchild) 

Especially  Prepared  as  a  Solvent  for 
Diphtheritic  Membrane. 


PEPTONISING  TUBES. 

*     (fairchild). 

For    the  preparation  of  PEPTO- 
NIZED MILK  and  other 
pre  digested  food  for 
the   sick. 


EXTRACTUM  PANCREATIS. 
(fairchild). 

Containing  all  the  digestive  ferments 
of  the  Pancreas. 


PEPSINE   IN  SCALES. 

(fairchild). 

The  most  active,  permanent  and  re- 
liable pepsine  made  in  the  World. 


ESSENCE  OF  PEPSINE 

(fairchild). 

For  administration    where   a  fluid 

and  agreeable  form  of  pepsine  is 

desired,  and  for  the  prep  ara- 

ration  of  Junket  and 

Whey. 


PEPTOGENIC  MILK  POWDER 

(fairchild). 

For  the   modification  of  cows'  milk 

to  the  standard  of  Normal 

Mother's  Milk. 


PEPSINE  IN  POWDER. 

(fairchild). 

Prepared  from  the  scales  without  the 
admixture   of  any   other  sub- 
stances, to  facilitate  dis- 
pensing and  the  pre- 
paration of  saccharated pepsine. 


DIASTASIC    ESSENCE 
PANCREAS. 


OF 


(fairchild). 
For  the    digestion  of  starchy  foods. 


Fairchild  Bros.  &  Foster, 


82  AND  84  FULTON  ST.,  NEW  YORK. 


SYPHILIS 


NERVOUS    SYSTEM 


H.  C.  WOOD,  M.  D.,  LL.  D. 


GEORGE  S.  DAVIS, 

DETROIT,    MICH. 


Copyrighted  by 

GEORGE    S.    DAVIS. 

1889. 


CONTENTS. 


CHAPTER  I. 

PAGE. 

Etiology 

CHAPTER  II. 

The  Brain  and  Its  Membranes I7 

Section      I— Pathology r_ 

II — Symptomatology 2o 

HI — Diagnosis 75 

IV — Prognosis gg 

V — Treatment qj 

CHAPTER  III. 

Spinal  Syphilis IQ2 

Section      I— Pathology io2 

II — Symptomatology IIO 

III— Prognosis 12, 

IV — Treatment I24 

CHAPTER  IV. 
The  Peripheral  Nerves I2Q 


PREFACE. 


At  a  time  like  the  present,  when  the  world  is  overflowing 
with  medical  writings,  it  seems  but  right  that  the  author  who 
would  lay  claim  to  a  portion  of  the  time  and  thought  of  his 
medical  brethren,  should  plainly  state  the  basis  on  which  his 
work  rests.  At  the  risk  of  being  considered  egotistic,  I  there- 
fore venture  to  say  that  the  present  brochure  is  largely  the  out- 
come of  personal  experience.  In  the  University  Hospital  and 
Dispensary,  there  have  been  treated  under  my  supervision 
five  thousand  cases  of  nervous  disease,  of  which  at  least  fifteen 
per  cent.,  or  seven  hundred  and  fifty,  have  been  in  the  persons 
of  syphilitics.  During  the  seventeen  years  of  my  service  at 
the  Philadelphia  Hospital,  there  were  under  my  care  about  two 
thousand  patients  suffering  from  various  affections  of  the 
nervous  system,  of  whom  more  than  fifty  per  cent,,  or  over 
one  thousand  had  suffered  from  syphilis.  To  these  seventeen 
hundred  and  fifty  cases  must  be  added  those  with  which  I 
have  come  in  contact  in  my  private  practice  and  as  consultant 
to  public  and  private  hospitals  for  the  insane— making  a  total 
of  nearly  two  thousand  cases. 


CHAPTER  I. 

ETIOLOGY. 

In  a  study  of  syphilitic  diseases  affecting  the 
nervous  system,  it  might  not  be  thought  necessary  to 
discuss  the  etiology  of  the  subject,  because  in  all 
cases  syphilis  is  primarily  the  cause  of  the  disorder; 
yet  many  questions  naturally  arise  in  connection  with 
the  relations  of  syphilis  to  the  nervous  system,  which 
require  notice. 

Certain  syphilitic  individuals  pass  through  a  long 
life,  and  through  a  long  series  of  specific  affections, 
without  the  nervous  system  being  implicated;  whilst 
in  other  cases  syphilis  early  selects  the  brain  or  spinal 
cord.  Rarely,  however,  are  we  able  to  explain  these 
differences,  or  to  discover  in  the  individual  case  any 
exciting  cause  of  the  attack  upon  the  nerve  centre.  It 
is  true  that  Fournierf  affirms  that  he  has  especially 
seen  the  disease  in  professional  and  other  men  whose 
brains  were  habitually  over-active,  and*  that  various 
other  authorities  attach  much  influence  to  over-study 
and  other  forms  of  cerebral  strain  as  exciting  causes 
of  brain  syphilis.  My  own  experience,  however,  hardly 
corresponds  with  this;  I  have  met  very  few  instances 
in  which  excessive  brain-work  unmistakably  appeared 
as  a  distinct  etiological  factor,  whilst  I  have  seen 
hundreds    of     cases    from    amongst    the     laboring 


f  La  Syphilis  du  Cerveau. 

2    GG 


class,  in  persons  in  whom  the  intellectual  faculties 
have  been  chiefly  dormant;  and  I  have  also  known 
numerous  cases  of  syphilis  occurring  in  intellectual 
workers,  without  specific  disease  of  the  nerve  centres. 
It  is  not  unnatural  to  expect  that  a  disease  or  a 
traumatism  which  is  capable  of  exciting  an  inflamma- 
tion of  the  nerve  centre,  may,  when  present  in  a  syph- 
ilitic person,  provoke  a  specific  explosion  in  such 
centre.  Thus,  thermic  fever  is  a  very  common  cause 
of  chronic  meningitis,  and  in  the  Journ.  de  Med.  et 
Chir.  (Paris,  1879,  p.  191)  a  case  is  reported  in  which 
cerebral  syphilis  followed  an  alleged  sunstroke.  In 
Roberts's  case  of  precocious  cerebral  syphilis  (herein- 
after reported),  the  first  convulsion  came  on  whilst  the 
man  was  fishing,  on  a  very  hot  day,  and  may  have 
been  precipitated  by  the  exposure.  In  a  case  which 
was  sent  to  me  from  a  neighboring  village  by  a  very 
intelligent  physician,  as  one  of  sunstroke  followed  by 
organic  brain  disease,  the  post  mortem  showed  that 
the  original  brain  lesion  was  a  gummatous  tumor 
involving  the  motor  centres,  and  it  is  much  more 
probable  that  the  primary  supposed  sunstroke  was 
really  an  epileptiform  convulsion,  the  first  of  the 
series  which  marked  the  coming  into  view  of  the  cere- 
bral disease,  than  that  the  gumma  was  produced  by 
the  sunstroke.  A  man  with  a  latent  gumma  in  his 
brain  might  very  well  have  an  epileptiform  attack  pro- 
voked by  exposure  to  excessive  heat:  and  if  sunstroke 
ever  is  the  starting  point  for  brain  syphilis,  such  cases 
must  be  rare. 


—  3  — 

Blows  and  other  traumatisms  do  not  seem  to 
figure  largely  as  exciting  causes  of  nervous  syphilis. 
I  have  seen  one  or  two  cases  of  specific  brain  disease 
attributed  to  violence  by  the  patient,  and  several 
cases  of  possibly  specific  spinal  disease — one  in  which 
a  poliomyelitis  followed  a  fall  on  the  ice;  one  in  which, 
after  a  fall  from  a  cart  and  marked  spinal  concussion, 
a  local  myelitis  developed;  and  one  of  a  general  mye- 
litis following  an  injury  by  a  horse.  The  only  records 
of  such  cases  known  to  me  are  those  reported  by 
Broadbent*  and  those  collected  by  Heubner.f 

A  very  important  question  connected  with  the 
etiology  of  nervous  syphilis  is  as  to  the  time  of  its  de- 
velopment. It  certainly  belongs  to  the  advanced 
stages  of  the  disorder,  and  usually  comes  on  some 
years  after  the  primary  infection;  but  I  have  seen  it  at 
every  period  from  one  year  to  thirty  years.  Fournier 
reports  intervals  of  twenty-five  years,  and  thinks  from 
the  third  to  the  tenth  year  is  the  time  of  maximum 
frequency  of  nervous  accidents. 

The  fact  that  nervous  syphilis  may  occur  many 
years  after  the  cessation  of  all  apparent  evidences  of 
the  diathesis,  is  of  great  practical  importance,  especi-' 
ally  as  the  nervous  system  is  more  prone  to  be  at- 
tacked when  the  secondaries  have  been  very  light 
than  when  the  earlier  manifestations  have  been  severe. 


*  London  Lancet,  1876,  ii,  p,  741. 
j'Ziemssen's  Cyclopedia,  xii,  p.  301. 


I  have  repeatedly  seen  brain  syphilis  in  persons  whose 
secondaries  had  been  so  slight  as  to  have  been  entirely 
overlooked  or  forgotten,  and  who  honestly  asserted 
that  they  had  never  had  syphilis,  although  they  ac- 
knowledged to  gonorrhoea  or  to  repeated  exposure, 
and  confessed  that  their  asserted  exemption  was  due 
to  good  fortune  rather  than  to  chastity. 

The  following  citations  prove  that  this  experience 
is  not  peculiar.  Dowse*  says:  "  Often  have  I  had 
patients  totally  ignorant  of  having  at  any  time  acquired 
or  experienced  the  signs  or  symptoms  of  syphilis  in  its 
primary  and  secondary  stages,  yet  the  sequelae  have 
been  made  manifest  in  many  ways,  particularly  in 
many  of  the  obscure  diseases  of  the  nervous  system." 
Buzzard  f  reports  a  case  of  nervous  syphilis  where  the 
patient  was  unconscious  of  the  previous  existence  of  a 
chancre  or  of  any  secondaries.  Rinecker  also  calls 
attention  J  to  the  frequency  of  nervous  syphilis  in 
persons  who  afford  no  distinct  history  of  secondary 
symptoms. 

Although  syphilis  is  prone  to  attack  the  nervous 
system  many  years  after  the  infection,  it  would  be  a 
'fatal  mistake  to  suppose  that  nervous  disease  may  not 
rapidly  follow  the  chancre.  What  the  minimum  possible 
intermediate  period  may  be,  we  do  not  know,  but  it  is 
certainly  very  brief,  as  is  shown  by  the  following  cases 


*The  Brain  and  its  Diseases,  London,  1879,  vol.  i,  p.  7. 
f  Syphilitic  Nervous  Affections,  London,  1874,  p.  80. 
X  Archiv  f.  Psychiatrie,  vii,  p.  241. 


—  5  — 
of  this  so-called  precocious  nervous  syphilis.     Alfrik 
Ljunggr6n,  of   Stockholm,    reports  ]    the  case  of   H. 

R ,  who  had  a  rapidly-healed  chancre  in  March, 

followed  in  May  of  the  same  year  by  a  severe  head- 
ache, mental  confusion,  and  giddiness.     Early  in  July 

H.   R had   an  epileptic   attack,   but  was  finally 

cured  by  active  antisyphilitic  treatment.  Although 
the  history  is  not  explicit,  the  nervous  symptoms  ap- 
pear to  have  preceded  the  development  of  distinct 
secondaries  other  than  rheumatic  pains. 

Davaine  is  said  §  to  have  seen  paralysis  of  the 
portio  dura  "  a  month  after  the  first  symptoms  of  con- 
stitutional syphilis."  E.  Leyden^[  found  advanced 
specific  degeneration  of  the  cerebral  arteries  in  a  man 
who  had  contracted  syphilis  one  year  previously.  R. 
W.  Taylor  details  a  case  in  which  epilepsy  occurred 
five  months  after  the  infection.*     In  the  case  of  M. 

X ,  reported  by  Ad.  Schwarz,f  headache  came  on 

the  fortieth  day  after  the  appearance  of  the  primary 
sore,  and  a  hemiplegia  upon  the  forty-sixth  day.  S. 
L 1  had  a  paralytic  stroke  without  prodromes  six 


H  Archiv  f.  Dermatol,  u.  Syphilis,  1870,  ii,  p.  155. 
§  Buzzard,  Syphilitic  Nervous  Affections,  London,  1874* 
TZeitschriftf.  klin.  Med.,  Bd.  v.  165. 
*  Jour.  Nervous  and  Mental  Dis.,  1876,  p.  38. 
fDe  1'  Hemiplegie   Syphilitique    Precoce,   Inaug.    Diss.' 
Paris,  1880. 
%  Ibid. 


—  6  — 

months  after  the  chancre.     A.  P.  L 1|  had  an  apo- 

pletic  attack  seven  months  after  the  chancre;  A.  S , 

one  five  months  after  her  chancre.  In  a  case  which 
recently  occurred  in  the  practice  of  A.  Sydney  Roberts 
of  this  city,  the  chancre  appeared  after  a  period  of  in- 
cubation of  twenty-six  days,  and  two  months  and  eight 
days  subsequent  to  this  came  the  first  fit;  eight  days 
after  the  first,  the  second  convulsion  occurred^with^a 
distinct  aura,  which  preceded  by  some  minutes  the 
unconsciousness.  An  interesting  observation  in  this 
connection  is  that  of  Ern.  Gaucher§  of  a  spinal 
syphilis  occurring  six  months  after  the  appearance  of 
a  chancre. 

This  citation  of  cases  might  be  much  extended, 
but  has  probably  already  gone  too  far,  and  I  must 
content  myself  with  referring  the  reader  to  the  Mem- 
oire  sur  les  Affections  Syphilitiques  Pre'coces  des  Centres 
Nerveux,  par  Charles  Mauriac,  Paris,  G.  Masson, 
Editeur,  1879,  and  to  the  Thesis  of  M.  Manchon  on 
Syphilis  Cerebrate  Pre'coce,  ~No.  407,  1883,  Paris.t.  In 
these  publications  are  collected  80  cases  of  precocious 
syphilis:  of  these  the  period  of  incubation^was: 

One  month 3  cases. 

Two  months 4  cases. 

Three  months *  6  cases. 

Four  months 8  cases. 

Five  months 14  cases. 


||  Ibid. 

§  Revue  de  Med.,  1882,  ii,  678. 


Six  months 7  cases. 

Eight  months   3  cases. 

Nine  months 4  cases. 

Ten  months I  case. 

Eleven  months 1  case. 

Twelve  months 29  cases. 

A  third  etiological  question  in  regard  to  syphilis 
of  the  nervous  system  is,  as  to  its  production  by  an 
inherited  taint,  as  well  as  by  an  acquired  infection. 
Inherited  syphilis  seems  to  be  less  prone  than  is 
acquired  syphilis  to  attack  the  nervous  system,  but  it 
is  certainly  capable  of  so  doing.*  As  early  as  1779, 
Joseph  Glenckf  reported  a  case,  of  a  girl  six  years 
old,  cured  by  a  mercurial  course  of  an  epilepsy  of 
three  years'  standing,  and  of  other  manifestations  of 
hereditary  syphilis.  Graefe  found  gummatous  tumors 
in  the  cerebrum  of  a  child  nearly  two  years  old. \  O. 
Huebner]  details  the  occurrence  of  pachymeningitis 
hsemorrhagica  in  a  syphilitic  infant  under  a  year  old. 
Hans  ChiariS  reports  a  case  in  which  very  pronounced 


*  It  is  worth  while  here  to  state  that  there  is  a  form  of 
paralysis  which  occurs  in  very  young  syphilitic  infants,  in  which 
a  monoplegia,  apparently  of  nervous  origin,  is  really  the  result 
of  a  syphilitic  affection  of  the  bones  of  the  affected  limb.  For 
an  elaborate  article  on  this  subject  by  M.  Laffitte,  see  Revue 
Mensuelle  des  Maladies  des  Enfants,  Vol.  5,  1887. 

f  Doctrina  de  Morbis  Veneris,  Vienna. 

%  Arch.  f.  Ophthalm.,  Bd.  i.  Erst  Abth. 

||  Virchow's  Archiv,  Bd.  lxxxiv,  269. 

§  Wien.  Med.  Wcchenschrift,  xxxi,  1881,  17. 


—  8  — 

syphilitic  degeneration  of  the  brain-vessels  was  found 
in  a  child  fourteen  months  old.  Both  Barlow^"  and 
T.  S.  Dowse*  report  cases  of  nerve  syphilis  in  male 
infants  of  fifteen  months.  For  other  similar  instances 
the  reader  is  referred  to  an  article  by  J.  Parrott,f  and 
to  a  paper  by  M.  E.  Troisier.^ 

Recorded  cases  prove  decidedly — fhat  a  foetus 
may  be  born  with  its  nervous  system  the  seat  of  gum- 
matous disease  —that  the  nervous  outbreak  may  occur 
at  any  time — and  that  even  after  puberty  specific  nerv- 
ous affections  may  primarily  attack  the  unfortunate 
offspring,  which  has  up  to  such  time  seemingly  escaped 
the  effects  of  parental  impurity.  Nettleship|  reports  the 
development  of  a  cerebral  gumma  in  a  girl  of  ten  years, 
and  J.  A.  Ormerod§  of  a  tumor  of  the  median  nerve 
(probably  gummatous)  in  a  woman  of  twenty-three, 
both  the  subjects  of  inherited  syphilis.  Thomas  S. 
Dowse**  details  a  case  of  cerebral  gumma  at  the  age 
of  ten  years,  and  Samuel  Wilksf  f  one  of  epilepsy,  from 
inherited  taint,  in  a  boy  of  fourteen.     J.  Hughlings- 


1"  Lond.  Patholog.  Soc.  Trans.,  1877. 

*  The  Brain  and  its  Diseases,  vol.  i.  p.  76. 

\  Archiv.  de  Physiologie,  1871-72,  p.  319;  also  to  his 
"Lecons  sur  le  Syphilis  hered.,"  Progres  med.,  1877  and  1878. 

%  Arch,  de  Tocologie,  x.  411. 

I  Trans.  Lond.  Path.  Soc,  xxxii,  13. 

§  Ibid.,  p.  14. 

**  Loc.  cit.,  p.  71. 

ff  Lectures  on  Dis.  of  Nerv.  Syst.,  Philadelphia,  1878,  p. 
333. 


Jacksonf  reports  paraplegia  with  epilepsy  in  a  boy  of 
eight,  hemiplegia  in  a  girl  of  eighteen,  and  hemiplegia 
in  a  woman  of  twenty-two;  J  the  nervous  affection  in 
each  instance  being  associated  with,  or  dependent 
upon,  inherited  syphilis.  E.  Mendel  ||  records  the 
history  of  a  child  who  enjoyed  fairly  good  health  until 
the  ninth  year  of  her  age,  when  she  suffered  from 
weakness,  with  swelling  of  the  glands  of  the  neck,  etc. 
At  eleven  years  of  age  she  was  attacked  with  nervous 
symptoms,  followed  by  delirium  and  hallucinations, with 
strabismus,  irregularity  of  the  pupils,  and  ending  in 
apathy,  convulsions,  and  death.  At  the  post-mortem, 
syphilitic  disease  of  the  brain  membranes  was  found. 
A  remarkable  case  is  reported  by  Prof.  Fournier 
(Union  Medical,  1884),  in  which  at  the  age  of  nine 
years,  the  child  was  well  nourished,  rosy,  vivaci- 
ous, and  very  intelligent,  but  commenced  occasionally 
to  wet  the  bed  at  night,  and  a  little  later  was  suddenly 
taken  with  a  violent  convulsion,  accompanied  by  com- 
plete loss  of  consciousness,  biting  of  the  tongue,  etc. 
Examination  showed  that  the  parents  of  the  child  had 
been  syphilitic,  and  that  at  the  age  of  three  months, 
the  child  herself  had  unmistakable  manifestations 
of  the  hereditary  disorder,  from  which  she  had  re- 
covered under  treatment.  After  the  first  epileptic  at- 
tack, the  symptoms  continually  increased  in  severity, 


f  Journal  of  Ment.  and  Nerv.  Diseases,  1875,  p.  516. 
X  Brit,  Med.  Journal,  May  18,  1872. 
(1  Archiv  f.  Phsychiatrie,  Bd.  i.  313. 


IO    

the  convulsions  recurring  frequently;  the  disposition 
of  the  child  slowly  changed,  and  ocular  paralysis  came 
on,  followed  after  a  time  by  loss  of  muscular  power, 
and  irregular  intermittent  muscular  contractions;  still 
later  the  child  became  idiotic, 'and  at  last  died  hemi- 
plegic  and  comatose.  At  the  autopsy  indisputable 
syphilitic  disease  of  the  brain  and  its  membranes  was 
found. 

In  the  Revue  Generale  D'Ophtalmologie,  Vol.  6, 
p.  97,  Dr.  V.  Caudron  details  the  case  of  a  young 
woman  17  years  of  age,  with  a  history  of  having  been 
a  somewhat  delicate  but  generally  healthy  child,  who 
had  undergone  general  bodily  development  with  the 
usual  rapidity.  There  had  been  none  of  the  custom- 
ary manifestations  of  hereditary  syphilis,  nor  were 
there  any  cicatrical  marks  on  the  skin  or  mucous 
membranes;  but  she  was  found  to  be  suffering  from 
undoubted  inherited  syphilis. 

A  number  of  cases  similar  to  those  which  I  have 
just  stated,  have  been  reported  in  America  by  Dr. 
Albert  H.  Buck  and  by  Dr.  Knapp,  of  New  York,  and 
by  Dr.  Kipp.  (See  New  York  Medical  Record,  Oct.  1, 
1887.) 

I  have  myself  known  cerebral  syphilis  to  occur  at 
21  years  of  age,  as  the  result  of  the  inherited  taint, 
and  report  here  in  detail  a  case  which  was  during  the 
life,  of  especial  interest  on  account  of  the  curious"  mix- 
ture of  hysterical  and  organic  symptoms.  The  hys- 
terical symptoms  were  so  pronounced,  and  the  history 


of  hysterical  selfishness  so  clear,  that  the  case  was 
brought  to  me  originally  as  one  of  hysteria  in  which 
deception  was  being  attempted  for  selfish  purposes. 
At  my  first  visit,  however,  I  thought  I  detected  under- 
lying evidences  of  organic  brain  disease,  and  the  sub- 
sequent examination  of  the  eyes  revealed  the  presence 
of  pronounced  choked  disks. 

Bertha  C,  aged  20;  mother  and  father  dead;  said  to  have 
been  healthy  as  a  babe  and  child,   but  history  not  very  clear. 
She  came  under  my  care  June,  1888;  about  a  year  previous  she 
had  suffered  from  a  violent  attack  of  illness  and  had  been  more 
or  less  sick  ever  since  with  malaise,  loss   of  weight,   excessive 
headaches,     repeated    vomiting     and     constipation.        Under 
homoeopathic  treatment  the  symptoms  had  abated,  but  in  April 
or  May  of  1888,  she  began  to  have  nervous  spells  which  (I  copy 
now  from  my  note  book)  "she  states  come  on  suddenly,  some- 
times with  the  hearing  of  a  loud   noise.       It   is   affirmed   that 
during  the  spell  she  is  entirely  unconscious  and  very  pale,  and 
that  there  are  peculiar  movements  of  the  head  after  the  attack. 
It  is  also  stated  that  at  one  time  she  lost  the  power  to  use  her 
hands,  so  that  she  was  not  able  to  feed  herself."     July  13th,   I 
noted:   "  There  is  no  failure  of  memory  or  mental  activity,  and 
no  evidences  of  palsy,  although  the  movements  of  the  hands 
are  slow  and  unsteady,   as  is  also  the  step,    but   there    is    no 
evidence  of  lack  of  co-ordination.      She   habitually    sits   in    a 
very  peculiar  position,  with  buttocks  slid  forward  just  to  the 
edge  of  the  chair,  and  the  upper  portion  of  her  neck  and  the 
back   of  head   resting   on   the  chair.     She  says  she  does  this 
"  because  it  rests  her  head."      There  is  a  distinct  callosity  of 
the  neck  from  this  habitual  pressure.      There  is  pronounced 
protuberance  of  the  lower  cervical  vertebrae,  but  no  tenderness 
on  jarring  or  pressure.     There  is  marked  stiffness  of  the  mus- 
cles of  the  neck,  and   the   optic   disks   are   choked,  but  vision 


12    

is  nearly  normal.  There  is  no  sense  of  constriction  in  the 
abdomen  or  other  portions  of  the  trunk;  no  disturbance  of 
general  sensibility;  but  the  patient  complains  much  of  pricking 
pains  in  the  stomach,  and  is  very  emotional  with  pronounced 
hysterical  symptoms."  She  was  put  on  the  use  of  iodide  of 
potassium,  and  of  corrosive  sublimate,  and  reported  herself 
July  9th  as  much  improved;  but  there  was  at  this  time  dis- 
tinct stiffness  in  the  back  of  the  neck,  and  she  had  had  one  or 
two  fainting  spells  in  the  last  week.  Owing  to  my  absence 
from  the  city,  the  case  was  after  this  seen  by  Dr.  F.  X.  Der- 
cum,  who  reported  as  follows: 

August  16,  1888.     I  was  suddenly  summoned  at   6  A.    m. 

to ,  was  told  that  Miss.  B.  had  fallen  from  a  window.     I 

found  her  lying  on  a  mattress  in  the  parlor.  Examined  her 
from  head  to  foot  but  found  no  trace  of  injury, — nothing  but  a 
doubtful  bruise  in  the  small  of  the  back.  She  complained  of 
great  pain  both  in  the  back  of  the  head,  shoulders,  arms, 
and  in  the  right  side  of  the  head  and  the  right  eye.  She 
appeared  to  be  extremely  hysterical,  and  resisted  movement  of 
the  painful  (?)  parts.  However,  when  the  latter  were  moved 
by  stealth  no  signs  of  pain  were  noticed.  This  was  noticeably 
the  case  with  the  right  arm,  and  which  she  in  addition  stoutly 
maintained  was  paralyzed,  when  later,  thinking  she  was  un- 
noticed, was  seen  to  move  it  quite  freely. 

Occasionally  she  gave  vent  to  shrill  and  piercing  screams, 
but  it  was  difficult  to  believe  they  were  not  hysterical,  her  emo- 
tional exaltation  being  so  marked.  The  moment  I  became  sympa- 
thetic in  my  demeanor  she  permitted  free  handling  of  the  pain- 
ful (?)  parts,  and  I  then  carried  her  upstairs  to  bed.  I  examined 
her  person  even  more  carefully  than  before,  but  with  the  same 
negative  result. 

I  now  looked  at  the  window  from  which  I  had  been  toM 
she  had  fallen.  In  height  it  was  about  twelve  feet  from  the 
ground;  below  it  was  a  wooden  porch,  a  fall  upon  which  certainly 


—  13  — 

would  entail  some  bruises.  She  had  been  found  lying  on  the 
porch  directly  beneath  the  window  about  four  o'clock  in  the 
morning.  She  was  crying  as  though  in  pain,  appeared  to  be 
perfectly  conscious,  and  said  she  had  fallen  out  of  the  window. 

On  inquiry  I  learned  that  the  window  had  been  found  wide 
open,  and  also  I  learned  the  following  interesting  facts:  Her 
bedroom  door  was  found  unlocked  and  a  window  on  the  first 
floor  was  found  unfastened.  On  further  inquiry  I  was  told 
that  the  girl  was  often  hysterical,  and  that  she  frequently  did 
things  to  provoke  sympathy.  Again,  I  learned  that  her  sister 
had  lately  been  reading  a  novel  to  her,  in  which  a  somnambu- 
list was  a  prominent  character.  She  evidently  had  been  much 
impressed  by  the  somnambulistic  performances  in  this  book, 
and  she  frequently  spoke  about  them.  So  great  was  her  inter- 
est in  this  novel  that  the  fact  attracted  the  attention  of  the 
family. 

The  logical  inference  appeared  to  be,  that  the  patient 
in  an  attack  of  real,  or  more  probably  simulated,  sonambulism, 
had  opened  wide  the  window  and  blinds,  and  then  stealthily 
crept  down  stairs,  and  by  means  of  a  first  floor  window  made 
her  exit  from  the  house.  She  then  lay  down  on  the  porch 
immediately  beneath  the  window,  and  moaned  until  her 
sister  sleeping  in  the  room  above  was  wakened.  The  household 
was  at  once  thrown  into  great  excitement,  a  neighboring 
physician  was  hastily  summoned,  and  she  was  instantly  the 
centre  of  anxious  inquiries,  loving  endearments,  and  frantic 
caresses.     Her  object  was  certainly  un  fait  accompli. 

The  next  day  patient  appeared  much  better,  was  sitting 
up,  walked  around,  and  almost  free  from  pains  except  those  in 
the  back  of  the  head  and  neck. 

August  18th,  1888.  After  presenting  nothing  unusual, 
she  complained  of  feeling  badly,  and  lay  down  on  her  bed 
about  8  o'clock  in  the  evening.  The  nurse,  a  well  trained 
woman,  noticed  that  shortly  afterward  she  had  a  fit,  during 


—    14   — 

which  the  head,  shoulders,  and  back  became  stiff,  and  arched 
backward,  "like,"  said  the  nurse,  "  I  have  seen  in  hysterical 
people."  Consciousness  appeared,  however,  to  be  entirely 
absent.  In  a  few  minutes  consciousness  returned,  and  the 
patient  spoke  a  few  words,  complaining  greatly  of  pain  in  the 
head.  In  a  quarter  of  an  hour  another  seizure  occurred, 
longer  and  more  severe  than  the  first;  the  head  being  jerked 
violently  backward.  When  it  had  been  subdued,  the  patient 
could  not  be  roused;  she  was  dead. 

Post  jnortem. — Scalp  normal;  shows  slight  ecchyrcosis  over 
vertex  (caused,  probably,  by  head  striking  top  of  bed).  Calva- 
rium  normal.  Dura  not  adherent;  inner  surface  smooth,  but  very 
dry.  Brain  bulging,  pale  and  tolerably  firm.  Surface  of  pia 
very  dry.     Very  little  blood  in  veins. 

Base  of  brain:  Meshes  of  pia  and  arachnoid  cedematous 
with  excessive  gelatinous  infiltration  over  pons,  crura,  and 
medulla,  especially  of  all  portions  lying  in  the  posterior 
cranial  fossa.  Infundibulum  excessively  distended  and  giving 
the  appearance  of  a  thin  walled  cyst.  Third  ventricle  ex- 
tremely dilated;  lateral  ventricles  somewhat  villous.  Choroid 
plexuses  very  cystic.  White  matter  of  brain  and  cortex  reveal 
nothing  abnormal. 

Base  of  skull  reveals  a  healthy  dura,  except  perhaps  in 
the  posterior  cranial  fossa,  where  it  seems  thicker  and  softer 
than  normal. 

Unfortunately  no  microscopic  examination  was  made 
because  the  family  objected  so  strenuously  to  its  being  done, 
and  would  not  allow  the  cutting  of  any  portions  of  the  cere- 
brum. A  very  careful  macroscopic  survey  of  the  membranes 
and  brain  vessels  was,  however,  made,  to  determine  the  pres- 
ence of  tubercles,  but  none  were  found.  The  father  had  been 
very  dissipated,  and  the  gross  character  of  the  lesions  was  dis- 
tinctly syphilitic.  The  fact  that  the  cerebral  symptoms  lasted 
for  over  a  year  before  the  fatal  result,  is  a  strong  argumen, 
against  there  having  been  tubercle. 


—  i5  — 

When  a  syphilitic  nervous  affection  first  develops 
in  a  child  ten  or  more  years  old,  in  whom  there  has 
been  no  pronounced  evidence  of  the  inherited  taint, 
there  is  great  danger  of  the  character  of  the  case  being 
misunderstood.  Indeed,  in  some  instances  I  have 
seen,  I  believe  an  immediate  diagnosis  was  scarcely 
possible.  It  is  probable  that  in  most,  if  not  all,  of  the 
alleged  recoveries  from  tubercular  meningitis,  the  dis- 
ease has  been  syphilitic.  A  child,  reported  to  me  by 
a  very  good  practitioner  as  having  been  cured  of  tuber- 
cular meningitis,  subsequently  came  under  my  care, 
and,  I  am  sure,  suffered  from  hereditary  syphilis.  Some 
time  since  I  saw  in  my  University  clinic  an  orphan 
child,  fourteen  years  of  age,  suffering  from  a  chronic 
basal  meningitis,  and  in  the  absence  of  any  history  or 
of  any  evidences  of  syphilis,  I  gave  the  fatal  prognosis 
of  tubercular  disease;  but,  to  my  astonishment,  after  a 
prolonged  treatment  with  iodides,  complete  recovery 
was  obtained.  Cases  in  which  chronic  basal  menin- 
gitis has  resulted,  in  young  children,  from  inherited 
syphilitic  taint,  have  also  been  given  by  F.  Dreyfous.* 

It  is  of  the  utmost  importance  to  recognize  that 
an  apparently  tubercular  meningitis  is  really  due  to 
hereditary  syphilis.  Without  a  history,  certainty  may 
not  be  possible,  but  a  general  indefiniteness  of  symp- 
toms and  slowness  of  progression  should  arouse  sus- 


*  Revue  mensuelle  des   Malad.  des  Enfants,  1883,  i,  497; 
see  also  Gaz.  hebdom.  Sci.  med.  de  Montpellier,  1883,  v,  89. 


—  i6  — 

picion,  especially  if  the  absence  of  pulse  retardation, 
or  the  presence  of  any  characteristic  symptoms,  indi- 
cate that  the  vault  rather  than  the  base  of  the  cranium 
is  involved. 

The  relation  of  inherited  syphilis  to  various  nerv- 
ous affections  not  distinctly  specific,  cannot  yet  be 
positively  determined;  but  arrested  development  and 
the  consequent  epilepsy,  idiocy  (see  Brain,  vol.  vii, 
404),'  and  early  brain  sclerosis,  are  probably  some- 
times the  outcome  of  such  inheritance;  and  the  cases 
collected  by  E.  Mendel  *  show  that  chronic  hydro- 
cephalus is  frequently  of  specific  origin. 


*Archiv.   f.    Psychiatrie  Bd.,  i,  309;  see  also  Virchow's 
Archiv.  Bd.,  xxxviii,  129) 


CHAPTER  II. 

THE  BRAIN  AND  ITS  MEMBRANES. 
Section  I.     Pathology. 

There  is  much  reason  for  believing  that  there  is  a 
close  connection  between  syphilis  and  sclerosis  of  the 
nerve  centres;  but  in  the  present  brochure  are  con- 
sidered only  those  affections  which  are  indisputably, 
directly  syphilitic.  There  are  two  lesions  of  the  cere- 
brum belonging  in  this  category,  which  for  pre- 
sent purposes  may  well  be  considered  distinct,  al- 
though their  relations  are  in  nature  very  close— if 
they  be  not  indeed  different  manifestations  of  the 
same  thing.  The  first  of  these  is  gummatous  menin- 
geal inflammation:  the  second,  disease  of  the  blood 
vessels;  beside  these  two  is  a  third  lesion  or  affection, 
meningo-encephalitis,  whose  relations  with  syphilis  is 
very  close,  but  whose  nature  has  not  hitherto  been 
well  made  out. 

As  has  been  taught,  by  Rindfleisch,  Fournier, 
Wagner,  and  others,  the  gummatous  tumor  probably 
always  commences  in  the  sheath  of  the  arterioles,  and 
by  the  formation  of  minute  cells,  which,  as  was  in- 
sisted upon  by  Wilks  in  1863,  are  produced  by  the 
proliferation  of  the  nuclei  which  lie  immediately  un- 
der the  vascular  endothelium.  Heubner,  seems  to  me 
correct   in  teaching  that  a  localized  gummatous  in- 

3   GG 


—  18  — 

flammation  always  starts  in  the  brain  membranes,  and 
never  in  the  brain  substance;  although  Fournier, 
whilst  admitting  the  peripheral  origin  of  most  gumma, 
still  claims  that  they  are  not  always  meningeal.  I  have 
never  seen  a  gummatous  brain  tumor  which  had  not 
really  sprung  from  the  brain  membranes,  although  a 
number  have  come  under  my  notice  which  were  situ- 
ated within  the  brain,  and  might  be  supposed  to  have 
arisen  in  the  brain  itself.  Always,  however,  they  had 
come  from  an  infolding  of  the  pia-mater  in  some  deep 
fissure,  or  from  the  velum  interpositum  in  the  lateral 
ventricles.  The  most  common  seat  of  the  tumor 
or  gummatous  inflammation,  is  the  base  of  the  brain, 
and  it  is  very  frequently  found  in  the  neighborhood  of 
the  pons  varolii  and  corpora  quadrigemina.  It  may, 
however,  locate  itself  upon  the  vault  of  the  cranium, 
and  in  my  experience,  has  been  especially  frequent  in 
the  anterior  and  motor  regions  of  the  cortex;  not 
rarely,  especially  affecting  the  immediate  neighborhood 
of  the  Rolandic  fissure. 

The  gummatous  mass  is  usually  surrounded  by 
a  reddish  zone  of  inflamed  nerve  tissue,  into  which 
it  is  sometimes  fused.  It  may  exist  as  a  roundish, 
isolated  tumor,  but  more  usually  is  spread  out,  irregu- 
lar in  shape,  and  more  or  less  confluent  with  the 
brain  beneath  it.  When  there  is  wide  spread  men- 
ingeal inflammation,  the  exudation  is  often  large, 
constituting  an  extended,  formless,  gelatinous  mass; 
this   form   of  gummatous   exudation    is   much   more 


—   i9  — 

frequently  met  with  at  the  base  than  at  the  vault 
of  the  cranium.  The  cerebral  gumma  varies  in  size 
from  a  mere  grain  to  a  mass  several  inches  in  length, 
and  is  very  apt  to  be  multiple.  Its  color  is  whitish  or 
yellowish,  or  occasionally  reddish,  according  as  it  has 
undergone  degeneration,  and  is  more  or  less  vascular. 
Not  rarely  two  distinct  zones  exist  in  the  gumma,  the 
inner  one  being  dry,  yellowish  in  color,  opaque,  and 
resembling  somewhat  the  region  of  caseous  degenera- 
tion in  the  tubercle,  whilst  the  outer  is  pinkish,  and 
more  or  less  semi-translucent. 

The  only  lesion  with  which  the  cerebral  gumma  can 
be  readily  confused  is  tubercle,  and  usually  the  distinc- 
tion is  easy.  Rarely  is  the  mass  so  spherical  as  that  of 
tubercle;  moreover,  it  is  usually  surrounded  by  a  zone 
of  reddish  tissue,  which  is  commonly  wanting  in  tuber- 
cle; then  it  is  never  completely  caseous,  as  it  does  not, 
like  the  tubercle,  undergo  degeneration  uniformly  and 
regularly.  Moreover,  it  much  more  frequently  gives  rise 
to  cerebral  softening,  than  does  tubercle.  There  are, 
however,  some  cases  in  which  it  is  necessary  to  study 
the  tumor  with  the  microscope  in  order  to  distinguish 
it  with  certainty  from  tubercle. 

On  microscopic  examination  of  a  cerebral  gumma, 
the  most  characteristic  structures  to  be  detected  are 
small  cells,  such  as  are  found  in  gummatous  tumors  in 
other  portions  of  the  body.  These  cells  are  most 
abundant  in  the  inner  zone,  which,  indeed,  may  be 
entirely  composed  of  them.      In  the   centre  of   the 


20    

tumor  they  are  more  or  less  granular  and  atrophied; 
in  some  cases  the  caseous  degeneration  has  progressed 
so  far  that  the  centre  of  the  gumma  consists  of  minute 
acicular  crystals  of  fat.  In  the  external  or  peripheral 
zone  of  the  tumor  the  mass  may  pass  imperceptibly 
into  the  normal  nerve  tissue,  and  under  these  circum- 
stances it  is  that  it  contains  the  spider-shaped  cells  or 
stellate  bodies  described  by  Jastrowitch,  and  especi- 
ally commented  upon  by  Charcot  and  Gombault,  and 
by  Coyne.  These  are  large  cells  containing  an  ex- 
aggerated nucleus  and  a  granular  protoplasm,  which 
continues  into  multiple,  branching,  rigid,  refracting 
prolongations,  which  prolongations  are  scarcely 
stained  by  carmine.  Alongside  of  these  cells  other 
largish  cells  are  often  found  without  prolongations, 
but  furnished  with  oval  nuclei  and  granular  proto- 
plasm. Amongst  these  cells  will  be  seen  the  true 
gummatous  cells,  as  well  as  the  more  or  less  altered 
neuroglia  and  nerve-elements.  In  the  perivascular 
lymphatic  sheaths  in  the  outer  part  of  the  gumma  is 
usually  a  great  abundance  of  small  cells.  The  spider- 
shaped  cells  are  probably  hypertrophied  normal  cells 
of  the  neuroglia,  and  have  been  considered  by  Charcot 
and  Gombault  as  characteristic  of  syphilitic  gummata 
of  the  brain.  In  a  solitary  gumma,  however,  of  con- 
siderable size,  from  the  neighborhood  of  the  cere- 
bellum, studied  by  Coyne  and  Peltier,  there  were  no 
stellate  cells.  Coyne  considers  that  their  presence  is 
due  to  their  previous  existence  in  the  normal  state  of 
the  regions  affected  by  the  gumma. 


Exactly  how  syphilitic  gumma  of  the  brain  are 
removed  in  cases  of  recovery,  it  is  difficult  to  deter- 
mine. It  is  certain  that  they  become  softened,  and 
disappear  more  or  less  completely;  and  it  is  probable 
that  the  cicatrices  or  the  small  peripheral  cysts  which 
are  not  rarely  found  in  the  surfaces  of  the  brain  are 
oftentimes  remnants  of  gummatous  tumors.  In  a 
number  of  cases  collected  by  Gros  and  Lancereaux 
there  were  small  areas  of  softened  tissue,  or  small 
calcareous  and  caseous  masses,  or  cerebral  lacunae  cor- 
responding to  the  cicatrices  of  softening,  or  imperfect 
cysts,  coincident  with  evidences  of  syphilis  elsewhere. 
V.  Cornil  also  states  that  he  has  found  small  areas  of 
softening  with  well-established  syphilitic  lesions  of  the 
dura  mater  and  cranium,  but  believes  that  the  lacunae 
or  cysts  depend  rather  upon  chronic  syphilitic  lesions 
of  cerebral  arteries  than  upon  gummatous  inflamma- 
tion. 

When  a  gummatous  tumor  comes  in  contact  with 
an  artery,  the  latter  is  usually  compressed  and  its 
walls  undergo  degeneration.  The  specific  arteritis 
may  pass  beyond  the  limit  of  the  syphilome  and  ex- 
tend along  the  arterial  wall.  Not  rarely  there  is  un- 
der these  circumstances  a  thrombus,  and  if  the  artery 
be  a  large  one,  secondary  softening  of  its  distributive 
brain-area  occurs. 

Cortical  Syphilis. — Our  knowledge  of  the  lesions 
of  the  brain  cortex  produced  by  syphilis,  is  im- 
perfect and  uncertain,  but  there  seem  to  to  be  two 
conditions  which  require  notice  here. 


22    

The  first  of  these  varieties  is  a  diffused  gumma- 
tous infiltration  of  a  wide  territory  of  the  cortex,  with 
or  without  pronounced  exudation  in  the  cerebral  mem- 
brane. This  syphilitic  infiltration  is  probably  always 
attended  with  irritation  of  the  pia  mater,  and  aggluti- 
nation of  this  with  the  brain  substance.  I  have,  at 
various  autopsies,  seen  the  brain  substance  involved 
with  the  under  surface  of  an  irregular  gummatous 
exudation,  which  apparently  had  sprung,  first  from  the 
the  membranes,  and  most  of  the  cases  of  recorded 
cortical  disease  are  of  this  character.  Moreover,  I 
have  never  seen  cases  in  which  the  main  infiltration 
was  in  the  cortex  of  the  brain  itself  and  the  membranes 
only  slightly  or  secondarily  involved.  Such  cases 
must  be  extremly  rare.  The  descript*  3ns  of  the  older 
writers,  without  careful  microscopic  studies,  are  of  no 
value  in  determining  the  existence  of  syphiltic  infiltra- 
tion of  the  cerebral  cortex,  and  the  satisfactory  cases 
are  very  infrequent  in  medical  literature.  Two  in- 
stances are  very  briefly  recorded  by  Rumpf,*  who  sim- 
ply states  that  he  found  a  diffuse  syphilitic  disease  of 
the  capillaries  and  small  arteries  in  the  brain  cortex: 
the  symptoms  during  life  having  more  or  less  closely 
resembled  those  of  dementia  paralytica. 

Heubner   reports   a   case   recorded   by  Schule.f 


*  Die  Syphilitischen  Erkrankungen  des  Nervensystems, 
P.  159- 

f  Ziemssen  Cyclopoedia  of  Practical  Medicine,  vol.  xii, 
P-  31. 


—  23  — 
The  symptoms  had  been  those  of  dementia  paralytica, 
with  frequent  outbreaks  of  confirmed  constitutional 
syphilis,  and  the  patient  had  been  in  an  asylum  for 
twenty  years.  At  the  autopsy  there  were  found,  be- 
side a  circumscribed  gummatous  inflammation  between 
cranium  and  dura  mater: 

"A  hemorrhegic  pachymeningitis,  an  old  opacity  and 
thickening  of  the  soft  membranes,  and  an  atheromatous  de- 
generation of  the  large  arteries  of  the  base;  a  peculiar  pale 
gray,  as  it  were,  swollen  condition  of  the  cerebral  cortex;  a 
small  softening  of  the  left  nucleus  lenticularis;  and  a  gray  de- 
generation of  the  lateral  columns  of  the  spinal  cord,  chiefly  on 
the  left  side.  Upon  microscopic  examination,  it  appeared  that 
in  the  cerebral  cortex  the  texture  of  the  neuroglia  had  taken 
on  another  and  homogenous  quality,  and  was  abnormally  filled 
up  with  nuclei,  single  and  in  groups,  chiefly  along  the  vessels, 
which  were  themselves  much  altered.  Their  walls  were  thick- 
ened, sclerosed,  and  their  cells  had  undergone  fatty  degenera- 
tion, or  their  ^channels  were  accompanied  by  close  rows  of 
nuclei,  or  by  lines  of  spindled  cells,  others  being  surrounded 
by  a  dense  web  of  connective  tissue,  or  obliterated  so  as  to 
become  fibrous  bands.  The  ganglion  cells  were  shrunken  in 
various  degrees." 

The  second  variety  of  cortical  brain  lesion  is  not 
spoken  of  by  writers,  but  is  that  in  which  change  ap- 
pears to  be  a  subacute  inflammation  affecting  the  vessels 
and  the  neuroglia.  I  report  later  in  this  brochure,  in 
detail, -a  case  of  this  character. 

The  disease  occurred  in  the  person  of  a  young 
man  who  was  suffering  from  undoubted  syphilis,  and 
presented  during  life  many  of  the  symptoms  of  cere- 


—  24  — 

bral  syphilis.  In  this  case  the  alterations  had  appar- 
ently reached  their  fullest  extent  in  the  anterior  lobes, 
where  there  was  a  total  destruction  of  the  normal  nerve 
tissues;  towards  the  posterior  lobes  the  alterations  of 
the  cortical  structure  grew  less  and  less,  until  they 
gradually  disappeared  in  normal  tissue.  This  made 
it  possible,  in  the  single  case,  to  study  the  develop- 
ment of  the  lesion.  Whilst  in  the  anterior  portion  of 
the  brain  the  pia  mater  was  completely  adherent,  in 
the  posterior  portions  it  was  entirely  free.  It  was 
found  that  in  some  places  there  was  evident  structural 
alteration  of  the  cortex  without  the  pia  mater  being 
distinctly  abnormal,  even  the  vessels  of  the  cortical 
substance  being  more  diseased  than  those  of  the  pia 
mater,  showing  that  the  lesion  commenced  in  the 
brain  and  spread  from  it  to  the  membranes,  rather 
than  vice  versa.  In  portions  of  the  brain  in  which  the 
neuroglia  and  the  nerve  cells  appeared  to  be  entirely 
normal,  the  coats  of  the  blood  vessels  were  distinctly 
thickened,  and  the  walls  of  the  vessels  themselves  cov- 
ered externally  more  or  less  closely  with  small  cells, 
or  large  nuclei  imbedded  in,  or  adherent  around, 
them,  the  vascular  spaces  being  well  developed, 
perhaps  even  a  little  abnormally  large.  Here  and 
there  in  such  portions  of  the  tissue  would  be  found 
places  where  these  cells  had  aggregated  in  groups, 
or  small  masses,  about  some  larger  vessels.  In  the 
anterior  portions  of  the  brain  a  similar  condition  of 
the  vessels   was  found,  only  much  exaggerated,  the 


—  25  — 
walls  being  enormously  thickened,  and  the  small  cells 
or  large  nuclei  more  abundant;  but   no  where,  how- 


Fig.   I. 

Showing  edge  of  convolution  bordering  upon  inflamed  Pia 
Mater.  Arteriole  entering  between  convolutions,  showing 
Periarteritis.     X  250. 


—    26    — 

ever,  were  the  cells  aggregated  into  even  minute  gum- 
matous masses.     My  studies  indicated  clearly  that  the 


Fig.  2. 
Cross  Section  in  Pia  Mater.      X  250 

disease  commenced  in  the  external  coats  of  the  ves- 
sels, but  soon  involved  the  general  neuroglia  tissue,  the 


—   27   — 

whole  structure  being  more  or  less  filled  with  cellular 
elements  similar  to  those  found  adhering  to  the  vessels. 
At  the  same  time  there  was  a  destruction  of  the  proper 
nerve  tissue,  so  that  in  the  most  advanced  por- 
tions of  the  brain  the  cells  had  entirely  disappeared. 
In  this  portion  of  the  brain  were    also    found,    loosely 


Fig    3. 
Leucocytes  tending  to  organize  into  tissue.     X  5°°  (reduced). 

adhering  to  the  pia  mater,  curious  reticulated,  proto- 
plasmic (many  nucleated)  masses,  apparently  the  re- 
sult of  fusing  together  and  development  of  white 
blood  corpuscles  into  a  sort  of  connective,  tissue. 

Syphilis  of  the  Blaod  Vessels. — Syphilis  is  one 
of  the  most  frequent  causes  of  atheroma  of  the 
arteries,  and  in  syphilitic  subjects  atheroma  of  the 
vessels  of  the  brain  is  very  frequent.  As  in  the 
changes  which  it  causes,  as  well  as  in  the  course 
of   its    development,    it    does    not    differ   from    athe- 


28    — 

roma  elsewhere,  I  shall  not  discuss  its  pathology 
in  detail;  but  there  is  a  form  of  syphilitic  disease 
which  is  especially  prone  to  attack  the  arteries  at  the 
base  of  the  brain,  and  is  more  destructive  in  its  his- 
tory. The  first  change  in  the  blood  vessel  is  a  loss 
of  its  transparency,  with  the  development  of  a  peculiar 
whitish  appearance  which  increases  until  the  whole 
artery  is  grayish-white.  Little  by  little  the  vessel 
loses  its  flat  cylindrical  form  until  it  becomes  per- 
fectly round;  at  this  time  it  is  much  firmer  to  the 
touch  than  normal,  and  at  last  it  remains  stiff  and 
and  hard.  The  naked  eye  is  sufficient  to  show  that 
the  lumen  of  such  a  vessel  is  irregularly  encroached 
upon.  Under  the  microscope,  this  encroachment  is 
seen  to  be  due  to  zones  of  newly  formed  substance 
of  white  or  grey  color,  which  at  first  is  dry  and  tough, 
but  in  the  last  stage  hard  and  cartilaginous.  Accord  - 
to  Heubner,  this  newly-grown  substance  is  developed 
between  the  elastic  lamina  of  the  intima  and  the  endo- 
thelium, and  consists  at  first  of  endothelial  cells, 
which  constantly  increase  and  alter  until  they  form  a 
firm  felted  tissue  composed  of  spindle  and  stellate  cells, 
into  which  run  prolongations  from  the  nutritive  vessels. 
This  mass  may  increase  longitudinally,  involving  more 
and  more  of  the  main  artery.  It  may  become  organ- 
ized and  take  upon  a  structure  similar  to  that  of  the 
original  wall  of  the  vessel,  when  the  process  comes  to 
a  standstill  with  great  lessening  of  the  lumen  of  the 
vessels;  or  it  mav  be  transformed  into  a  fibrous  con- 


—  29  — 
nective  tissue,  the  whole  affected  portion  of  the  artery 
becoming  useless.  This  degeneration  especially  at- 
tacks the  carotids  and  their  branches,  the  arteries  of  the 
Sylvian  fissure  and  of  the  corpus  callosum,  near  their 
origins,  and  by  interference  with  the  terminal  arteries 
which  supply  the  corpus  striatum,  not  rarely  produces 
softening  of  it. 

The  disease  of  the  brain  cortex,  which  has  been 
spoken  of  as  connected  with  disease  of  the  vessels,  is 
probably  largely  dependent  upon,  and  secondary  to, 
the  affection  of  the  blood  vessels.  It  might  therefore 
well  be  considered  at  this  place,  had  it  not  already 
been  discussed  in  sufficient  detail. 

Syphilomata  may  produce  softening  and  breaking 
down  of  the  brain  tissue  by  pressure  upon  the  vessels, 
or  even  upon  the  brain  substance,  but  the  softenings, 
the  wide  spread  degenerations  of  brain  tissue  which 
are  so  frequent  in  syphilitic  subjects,  are  much  more 
frequently  due  to  disease  of  the  blood  vessels,  either 
alone  or  in  connection  with  syphilitic  disease  of  the 
membranes.  It  must  also  be  remembered  that  the 
peculiar  degeneration  described  in  the  last  paragraph, 
although  more  frequent  in  the  large  vessels,  may  oc- 
cur in  the  smallest  and  that  a  large  or  a  small  vessel  so 
diseased  is  unable  to  properly  exercise  its  function, 
and  very  frequently  becomes  the  seat  of  a  thrombus. 
Section  II.  Symptomatology. 
It  has  always  been  stated  that  syphilis  may  produce 
various  more  or  less  distinct  lesions  of  the  nerve  cen- 


—  3°  — 
tres.  It  must  be  remembered,  however,  that  it  is  not 
usual  for  one  of  these  lesions  to  exist  by  itself,  but  that 
in  any  individual  case,  usually  two,  or  perhaps  all  of 
them,  are  present.  Since  the  lesions  of  cerebral  syphilis 
vary,  it  is  evident  that  the  symptoms  of  the  dis- 
order must  also  vary:  moreover,  the  same  lesion 
occupies  now  this,  now  that,  brain  region,  and  as  the 
symptoms  which  it  produces  are  the  outcome  of  inter- 
ference with  the  function  of  the  part  of  the  brain 
immediately  implicated,  it  is  evident  that  the  same 
lesion  must  in  different  cases  cause  different  symp- 
toms: it  is,  indeed,  rare  to  find  two  cases  of  syphilitic 
brain  disease  offering  exactly  similar  symptoms  and 
running  parallel  courses,  so  that  it  is  difficult  to 
make  a  picture  of  a  typical  or  ideal  case  of  the  dis- 
ease. 

In  attempting  the  study  of  symptomatology,  it  is 
best  to  begin  with  gummatous  meningitis  as  the  most 
ordinary  form  of  the  specific  brain  affection.  As  the 
gummatous  mass  may  diffuse  itself  widely,  or  may  be 
strictly  localized,  under  the  head  of  gummatous  syph- 
ilis of  the  brain  membrane  are  included  cases  of 
localized  gummatous  tumors,  and  also  cases  of  syph- 
ilitic meningitis,  /.  e.,  cases  in  which  the  large  regions 
of  the  meninges  are  involved  in  an  inflammation  with 
gummatous  exudation. 

Gummatous  Syphilis   of  the  Brain  Membrane. 

Cases  of  gummatous  brain  syphilis  may,  for  our 
present  purpose,  be  very  well  divided  into  the  acute 


—  31   — 
and   chronic,  it  being  remembered  that  a  case  which 
in  its  onset  is  most  acute,  almost  invariably  ends  in  a 
chronic  disorder. 

Although  the  clinician  is  justified  in  talking  about 
acute  syphilitic  meningitis,  I  am  myself  much  inclined 
to  doubt  whether  acute  inflammation  of  the  brain 
membranes  or  of  the  brain  substance,  ever  develops 
as  a  primary  syphilitic  lesion.  It  seems  to  me  much 
more  probable  that  such  acute  inflammation  is  al- 
ways preceded  by  a  chronic  meningitis,  or  by  the 
formation  of  a  distinct  gummatous  tumor;  neverthe- 
less it  is  very  certain  that  acute  meningitis  may  de- 
velop in  a  case  when  there  have  been  no  apparent 
symptoms,  and  therefore  may  seem  to  be  absolutely 
abrupt  in  its  onset. 

Some  years  ago,  I  was  asked  to  see  in  consulta- 
tion, a  patient  who  was  suffering  from  a  partial  hemi- 
plegia as  the  result  of  an  attack  of  acute  brain  con- 
gestion, and  was  told  that  in  the  midst  of  apparently 
perfect  health,  the  man  came  home  from  business 
complaining  of  sleepiness,  was  shortly  afterwards 
found  comatose,  and  almost  immediately  after  this 
became  violently  convulsed.  The  convulsions  per- 
sisted for  some  time  under  the  administrations  of  a 
homoeopathic  practitioner;  the  doctor  who  was 
then  summoned,  found  the  patient  comatose,  fiercely 
convulsed,  with  a  full  bounding  pulse  and  high 
temperature.  Very  free  venesection  was  practiced 
and     the    patient    became    quiet,    although    still  un- 


—  32  — 
conscious.  A  few  hours  later  a  recurrence  of 
the  convulsive  movements  was  subdued  by  cupping 
the  back  of  the  neck.  Shortly  after  this  treatment  the 
convulsions  ceased,  the  respiration  became  regular, 
and  after  a  few  hours  consciousness  returned. 

After  this  return  to  consciousness,  however,  there 
was  slight  weakness  of  the  left  side,  which  in  the 
course  of  forty-eight  hours  had  distinctly  increased. 
Believing  that  the  case  was  one  of  syphilis,  I  suggested 
the  free  exhibition  of  mercury,  and  a  few  days  later 
my  diagnosis  was  confirmed  by  the  appearance  of  a 
plainly  specific  squamous  eruption  on  the  hand.  Un- 
der antisyphilitic  medication,  complete  recovery  was 
obtained.  In  this  case  the  mode  of  coming  on  and 
the  gradual  increase  of  the  hemiplegia  after  the  con- 
vulsion, indicated  that  a  latent  gumma  had  preceded 
the  acute  attack. 

Almost  always  very  careful  investigation  will,  in 
these  cases  of  acute  brain  syphilis,  show  that  there 
have  been  prodromic  symptoms  which  have  been 
overlooked.  As  an  example  I  may  cite  the  case  of  B. 
R.,  aged  28,  whom  I  also  saw  in  consultation.  It  was 
stated  that  in  the  afternoon  of  January  21,  1887,  with- 
out prodromes,  he  suddenly  became  dizzy  and  fell, 
the  fall  being  followed  by  light  delirious  stupor,  high 
fever,  very  rapid  pulse,  succeeded  after  some  hours  by 
clear  mental  action,  with  persistent  headache  and 
malaise,  and  five  days  later  by  an  epileptic  convulsion. 
In  this  instance,    however,   careful   cross-questioning 


—  33  — 
elicited    from    the    man's   wife   the    statement   that, 
although  he  had  been  attending  to  his  business  regu- 
larly up  to  January  21,  he  had  previously  complained 
of  great  drowsiness. 

The  further  course  of  this  case  is  sufficiently  interesting 
to  be  worthy  of  noting:  On  January  28th  there  was  weakness 
of  the  external  rectus  muscle  without  ocular  paralysis,  with 
violent  headache,  and  very  rapid  and  feeble  pulse  When 
left  to  himself,  Mr.  R.  continually  talked  nonsense,  but  when 
aroused  would  answer  questions  with  a  fair  degree  of  correct- 
ness. He  did  not,  however,  recognize  clearly  those  about  him, 
and  at  night  was  irrational  and  frequently  delirious,  with 
periods  of  profound,  almost  stuporous  sleep.  Under  active 
mercurial  treatment,  by  the  18th  of  February  he  was  much 
better,  but  on  that  day,  he  was  suddenly  seized  with  epilepti- 
form convulsions  lasting  for  some  hours,  followed  by  pro- 
longed hebetude  with  wandering  delirium  at  night,  great  head- 
ache, hallucinations,  retention  of  urine  and  strabismus. 
Mr.  R.  was  now  freely  ptyalized,  and  subsequently  given  a 
drachm  of  iodide  of  potassium  three  times  a  day.  By  the  2nd 
of  March  all  the  symptoms  had  vanished  and  convalescence 
seemed  fairly  established.  Early  in  May  he  returned  to  his 
business,  and  since  that  time  has  remained  in  good  health, 
under  the  continued  use  of  small  doses  of  the  iodide  of  potas- 
sium. 

Another  case  illustrative  of  the  form  of  syphilis 
now  under  consideration,  is  that  of  Patrick  McC,  who 
was  picked  up  by  the  police  patrol,  and  brought  into 
the  University  Hospital  as  a  case  of  apoplexy. 

He  was  profoundly  unconscious,  with  flushed  face  and 
conjunctiva, with  contracted  pupils  which  responded  very  feebly 
to  the  light;  pulse,  58;  temperature,   96.8.     He  remained  for 


—  34  — 

some  hours  in  a  condition  of  stupor,  with  retention  of  urine; 
but  calomel  being  very  freely  administered,  in  48  hours  he 
was  able  to  answer  questions  and  to  complain  of  headache. 
Under  the  continued  use  of  iodide  of  potash,  which  was  rapidly 
increased  to  a  drachm  three  times  a  day,  he  soon  conval- 
esced, and  in  two  weeks  after  his  admission  was  discharged 
from  the  hospital  without  the  appearance  of  any  symptoms. 
This  patient,  after  recovery  of  consciousness,  stated  that  he 
was  entirely  well  until  three  days  before  his  admission  into 
hospital,  when  he  was  seized  by  violent  headache  increased  by 
light,  giddiness,  ringing  of  the  ears,  and  a  marked  sense  of 
hebetude.  Unmistakable  evidences  of  syphilitic  infection, 
past  and  present,  were  upon  his  person. 

It  is  evident,  that  a  case  of  chronic  syphilis  may, 
at  any  time  suffer  from  an  epileptic  or  an  apoplectic 
attack,  readily  mistaken  for  an  acute  disease.  It 
is  perhaps  not  so  universally  recognized  that  a  sufferer 
from  a  chronic  syphilitic  brain  lesion  is  liable  to  an 
attack  of  not  only  simple  brain  congestion,  but  also  of 
an  acute  meningitis.  At  the  University  Hospital  Dis- 
pensary, I  once  made  the  diagnosis  of  chronic  cerebral 
syphilis  in  a  patient  who  the  next  day  was  seized  with 
violent  delirium,  and  typical  evidences  of  acute 
meningitis,  accompanied  with  excessive  pain  in  the 
head  and  convulsions.  After  the  convulsions  had 
persisted  for  four  days,  I  was  sent  for,  and  found  the 
man  offering  every  symptom  of  explosive  meningitis, 
and  after  his  death  it  was  discovered  that  an  acute 
meningitis  had  been  engrafted  upon  a  chronic  menin- 
gitis evidently  of  syphilitic  origin.     A  similar  case  to 


—  35  — 
this  is  reported  by  Gamel,*  in  which  intense  headache, 
fever,  and  delirium,  came  on  abruptly  in  an  old  syphil- 
itic subject,  and  ended  in  general  palsy  and  death. 
At  the  autopsy  the  symptoms  were  found  to  have  de- 
pended upon  an  acute  meningitis  secondary  to  a  large 
gumma. 

In  this  connection  may  well  be  cited  the  observa- 
tion of  Molinier  f  in  which  violent  delirium,  convul- 
sions, and  coma,  occurred  suddenly.  A  very  curious 
case  is  reported  by  D.  A.  Zambaco,];  in  which  attacks 
simulating  acute  meningitis,  occurring  in  a  man  with  a 
cerebral  gummatous  tumor,  appear  to  have  been  mala- 
rial. In  such  a  case  the  diagnosis  of  a  malarial  parox- 
ysm could  only  be  made  out  by  the  presence  of  the 
cold  stage,  the  transient  nature  of  the  attack,  its  going 
off  with  a  sweat,  its  periodical  recurrence,  and  the 
therapeutic  effect  on  it  of  quinine. 

The  symptoms  of  chronic  brain  syphilis  are  so  pro- 
tean, so  polymorphic,  sometimes  in  the  single  case  so 
kaleidoscopic  in  the  weekly  or  even  daily  shiftings 
and  combinations,  that  it  is  almost  impossible  to 
reduce  them  to  any  order.  Possibly  the  most  danger- 
ous cases  are  those  in  which  the  symptoms  are  least 
severe,  and  so  elusive  that  they  fail  to  call  attention  to 
the  existence  of  severe  organic  disease  of  the  brain. 


*  Inaug.  Diss.,  Montpellier,  1875. 
f  Revue  Med.  de  Toulouse,  xvi,  1880. 
X  Des  Affectiones  Nerveuses  Syphilitique,  Paris,  1862,  p. 
485. 


_   36  - 

Malaise,  a  little  brain  failure,  a  succession  of  causeless 
headaches — these  may  for  a  long  time  be  all  the  out- 
comes. The  following  outline  of  a  case  taken  from 
my  notebook  will  serve  to  illustrate  this  mild  form  of 
the  disorder: 

Mr.  A.  J.  F.,  aged  50,  was  first  seen  by  me  April  28, 
1880.  The  history  that  he  gave  was  that  during  1875  and  1876, 
being  the  head  of  a  large  corporation  engaged  in  legal  struggles 
for  existence,  he  was  under  great  strain  and  overwork,  and 
gradually  failed  in  health  until  April  1876,  when  he  was  sud- 
denly seized  with  partial  blindness,  and  loss  of  power  in  his 
legs.  This  continued,  at  times  worse,  at  times  better,  for 
some  months,  until  finally  he  was  forced  to  take  to  his  bed  with 
great  prostration,  and  mu  h  distress  in  the  head,  and  a  sense  of 
pressure  of  the  forehead.  July  1876  he  began  to  get  about, 
but  was  unable  to  attend  to  business;  any  mental  exertion 
brought  on  distress  of  the  head  with  confusion  of  thought. 
He  stated  that  he  had  never  had  any  distinct  spells  of  giddiness, 
but  much  numbness  about  the  head,  and  that  there  was  loss  of 
control  over  his  muscles  so  that,  to  use  his  words,  "  when  he 
wanted  to  change  position  he  could  not  tell  how  to  do  it." 
This  symptom  varied  in  intensity  from  time  to  time.  There 
had  been  distinct  failure  of  memory  for  recent  events,  but  no 
convulsive  attacks.  In  February  1880,  without  warning,  he 
fell  unconscious,  but  was  not  convulsed.  The  unconsciousness 
lasted  for  five  minutes  followed  by  delirium  and  great  excite- 
ment. Under  the  administration  of  chloral  he  went  to  sleep,  but 
it  was  several  days  before  he  recovered  completely.  Since  the 
beginning  of  the  illness  his  eyesight  had  not  been  very  good, 
but  he  had  obtained  some  imperfect  relief  from  glasses.  In  1878 
he  noticed  that  he  could  see  a  great  deal  better  in  the  night 
than  in  the  day, — in  the  day  everything  seemed  blurred.  Dur- 
ing all  these  years  he  had  been  a  good  walker;   no   disturbance 


—  37  — 

of  bladder  or  rectum  or  of  the  sexual  functions;  had  had  some 
tingling  in  the  hands  and  feet;  at  times  heard  very  distinctly 
bands  of  music,  voices,  etc. ; — the  hearing  of  these  sounds  was 
sometimes  so  distinct  as  to  deceive  him,  but  had  never  pro- 
duced any  mental  delusion;  there  had  been  no  visual  delusions; 
he  had  had  no  second  attack  of  unconsciousness.  April  28,  at 
the  time  he  came  under  my  care,  his  symptoms  according  to 
my  notes  were  as  follows:  "Appetite  and  digestion  good;  no 
disturbance  in  the  power  of  electro-muscular  contractility  or 
reflexes  of  the  arms  and  legs;  some  little  lack  of  sensibility  in 
the  legs  so  that  he  can  not  separate  the  points  of  the  aesthesio- 
meter  at  two  and  a  half  centimeters;  has  some  sensation  of 
numbness  on  the  right  side  of  the  head  associated  with  some 
loss  of  power  of  separating  the  aesthesiometrical  points  as  con- 
trasted with  the  opposite  side  of  the  head.  Vision  at  times 
perfect,  but  often  duplex,  and  not  infrequently  he  sees,  two, 
three,  four,  or  even  five  secondary  images,  all  the  secondary 
images  being  blurred.  There  has  been  distinct  change  of  dis- 
position, he  having  become  irritable  and  apathetic. 

Under  the  frequent  cauterization  of  the  neck  and  the  ad- 
ministration of  iodide  of  potassium,  Mr.  F's  symptoms  gradu- 
ally abated  and  after  some  months  he  left  me   perfectly  cured. 

March  13,  1886,  Mr.  F.  reported  at  my  office  with  symp- 
toms of  failure  of  health  accompanied  with  loss  of  power  to  do 
mental  work;  some  mental  confusion,  some  headache,  but 
more  pronounced  general  distress  in  the  head,  and  very  marked 
right  ptosis.  He  was  first  salivated,  and  afterwards  iodide  of 
potassium  was  administered  to  him  in  doses  of  half  a  drachm 
three  times  a  day,  associated  with  small  doses  of  mercurials. 
Under  this  treatment  he  greatly  improved,  and  by  June  had 
recovered  his  general  health,  and  also  the  use  of  his  right  eye- 
lid. 

Oct.  i883.  Mr.  F.  returned  suffering  from  the  old  symp- 
toms, with,  however,  the  ptosis  not  so   pronounced  as  before, 


-   38  - 

but  affecting  very  distinctly  both  eye-lids.      Under  the  use  of 
large  doses  of  iodide  and  mercurials  he  again  recovered. 

In  the  more  severe  cases  of  chronic  brain  syphilis 
which  have  come  under  my  observation,  most  usually 
after  a  greater  or  less  continuance  of  prodromes  such 
as  have  been  mentioned,  epileptic  attacks  have  oc- 
curred with  a  hemiplegia,  or  a  monoplegia,  which  is 
almost  invariably  incomplete,  and  usually  progressive; 
very  frequently  diplopia  is  manifested  before  the 
epilepsy,  and  on  careful  examination  is  found  to  be 
due  to  weakness  of  some  of  the  ocular  muscles.  Not 
rarely  oculo-motor  palsy  is  an  early  and  pronounced 
symptom,  and  a  marked  paralytic  squint  is  very  com- 
mon. Along  with  the  development  of  these  symptoms 
there  is  almost  always  distinct  failure  of  the  general 
health  and  progressive  intellectual  deterioration,  as 
shown  by  loss  of  memory,  failure  of  the  power  to  fix 
the  attention,  mental  bewilderment,  morbid  somnol- 
ence, perhaps  aphasia,  and  towards  the  end  of  life  not 
rarely  dementia.  If  the  case  convalesce  under  treat- 
ment, the  amelioration  is  gradual,  the  patient  travel- 
ing slowly  up  the  road  he  has  come  down.  If  the 
case  end  fatally,  it  is  usually  by  a  gradual  sinking  into 
complete  paralysis,  or  the  patient  is  carried  off  by  an 
acute  inflammatory  exacerbation,  or,  as  in  two  of  my 
cases,  amelioration  may  be  rapidly  occurring  and  a 
very  violent  epileptic  fit  produce  a  sudden  fatal 
asphyxia.  Death  from  brain-softening  around  the 
tumor  is  not  infrequent,  but  a  fatal  apoplectic  hemor- 
rhage is  rare. 


—  39   — 

I  do  not  think  much  is  to  be  gained  by  attempt- 
ing to  classify  cases  of  cerebral  syphilis,  but  Fournier 
separates  them  into  the  cephalic,  congestive,  epileptic, 
aphasic,  mental,  and  paralytic,  although  in  so  doing 
he  scarcely  facilitates  description  or  study.  Heubner 
makes  the  following  types: 

"i.  Psychical  disturbances,  with  epilepsy,  incom- 
plete paralysis  (seldom  of  the  cranial  nerves),  and  a 
final  comatose  condition,  usually  of  short  duration. 

"  2.  Genuine  apoplectic  attacks  with  succeeding 
hemiplegia,  in  connection  with  peculiar  somnolent 
conditions,  occurring  in  often-repeated  episodes;  fre- 
quently phenomena  of  unilateral  irritation,  and  gener- 
ally at  the  same  time  paralyses  of  the  cerebral  nerves. 

"  3.  Course  of  the  cerebral  disease  similar  to 
paralytica  dementia." 

In  regard  to  these  types,  the  latter  seems  to  me 
clear  and  well  defined,  but  contains  those  cases  which 
I  shall  discuss  under  the  head  of  Cortical  Disease. 

Meningeal  syphilis  as  seen  in  this  country  does 
not  conform  rigidly  with  the  other  asserted  types, 
although  there  is  this  much  of  agreement  that,  when 
the  epilepsy  is  pronounced,  the  basal  cranial  nerves 
are  not  usually  paralyzed,  the  reason  of  this  being 
that  epilepsy  is  especially  produced  when  the  gumma- 
tous change  is  in  the  ventricles  or  on  the  upper  cortex. 
In  basal  affections  the  epileptoid  spells,  if  they  occur 
at  all,  are  usually  of  the  form  of  petit  mal;  but  this 
rule  is  general,  not  absolute.     The  apoplectic  somno- 


—  4o  — 

lent  form  of  cerebral  syphilis,  for  some  reason,  is  rare 
in  this  city,  and  it  seems  necessary  to  add  to  those  of 
Heubner's,  a  fourth  type,  to  which  a  large  proportion 
of  our  cases  conform,  and  a  fifth,  and  still  more  rare 
form  of  the  disorder.  These  types  I  would  charac- 
terize as  follows: 

4.  Psychical  disturbance  without  complete  epilep- 
tic convulsions,  associated  with  palsy  of  the  basal 
nerves  and  often  with  partial  hemiplegia. 

5.  Paraplegia  associated  with  ocular  or  other 
symptoms  indicative  of  lesions  at  the  base  of  the 
brain. 

I  have  seen  a  number  of  cases  in  which,  along 
with  the  symptoms  of  disease  of  the  spinal  cord,  have 
been  present  evidences  of  implication  at  the  base  of 
the  brain,  such  as  headache,  dilatation  of  the  pupils, 
squint,  or  some  times  even  paralysis  of  the  facial, 
trigeminal,  or  other  basal  nerves  not  connected  with 
the  vision;  multiple  lesions  in  syphilis  of  the  nerve 
centres,  are  of  course  very  frequent,  and  in  the  cases 
now  under  consideration  I  believe  that  the  lesions 
existed  at  different  levels  upon  the  cord,  some  implicat- 
ing the  medulla  oblongata,  or  even  the  pons,  whilst 
others  are  placed  at  varied  heights  in  the  spinal 
column.  As  an  example  of  this  class  of  cases,  I  ap- 
pend an  account  of  one  which  was  long  under  my 
care.  The  history  of  syphilitic  infection  was  not  com- 
plete, but  the  character  of  the  symptoms  and  the  fact 
that  they  rapidly  yielded   to   anti-syphilitic   medica- 


—  41    — 
tion,  and  were  not  obviously  affected  by  other  treat- 
ment, is  sufficient  evidence  as  to  the  real  nature  of  the 
disease. 

X.  Y.,  aged  27,  has  no  knowledge  of  specific  infection, 
although  acknowledges  frequent  exposure.  Health  good  until 
March  14,  1884,  when  he  was  taken  with  a  general  feeling  of 
malaise  and  languor,  which  increased  for  a  week,  and  then  be- 
came so  bad  that  it  forced  him  to  go  to  bed.  At  this  time 
power  to  pass  water  failed,  so  that  his  urine  had  to  be  drawn 
off  by  catheter;  bowels  costive;  complete  anorexia;  great 
weakness;  some  headache,  and  dull,  steady  pain  in  the  arms, 
which,  with  restlessness,  kept  him  awake.  He  came  under  my 
care  April  7th;  at  this  time  bis  body,  and  especially  the  legs, 
were  emaciated.  The  notes  read:  "  Muscles  soft  and  flabby, 
and  reflexes  greatly  exaggerated,  especially  knee  jerk;  grasp  of 
hands  very  weak;  is  able  to  stand,  but  walks  very  feebly,  and 
only  a  few  steps,  with  much  staggering;  station  not  affected  by 
shutting  the  eyes;  aesthesiometer  shows  the  sensibility  de- 
cidedly impaired  in  the  legs,  normal  in  the  arms;  has  drooping 
of  right  eyelid  and  double  vision;  urine  has  to  be  drawn  with 
catheter;  suffers  no  pains,  except  some  dull  pain  in  the  arms." 

He  was  first  treated  with  alternate  hot  and  cold  water, 
douches  to  the  legs,  and  iodide  of  potassium.  He  improved 
steadily,  and  by  April  20th  the  double  vision  had  disappeared. 
On  the  20th  it  was  noted  that  vision,  the  bladder  functions, 
and  sensibility,  were  normal,  and  that  his  grip  was  stronger; 
but  the  legs  were  still  distinctly  weak,  although  he  was  able  to 
walk  a  little,  and  went  about  a  great  deal  on  crutches;  the 
knee  jerk  had  become  nearly  normal.  There  was  little  head- 
ache, but  a  great  deal  of  dizziness. 

The  large  doses  of  iodide  of  potassium  and  the  small 
doses  of  corrosive  sublimate,  were  continued  through  the  sum- 
mer, and  by  the  first  of  August  the  patient  was  able  to   walk 


—  42   — 

very  well.  Near  the  middle  of  August  he  recommenced  his 
office  work,  when  one  day,  after  standing  three  or  four  hours, 
a  sense  of  weakness  developed  in  the  legs,  which,  in  spite  of 
treatment,  grew  steadily  worse,  until  he  was  forced  to  take  up 
crutches  again.  Simultaneously  with  the  lameness,  there  de- 
veloped pain  in  the  elbows  very  similar  to  that  from  which  he 
had  first  suffered;  also  headache.  There  was  no  return  of  the 
urinary  symptoms,  except  occasionally  slowing  or  arrest  of 
the  passing  of  the  urine. 

The  iodide,  which  he  had  been  taking  through  the  summer 
in  small  doses,  was  increased  to  rso  grains  a  day.  In  four  days 
slight  evidences  of  iodism  developed,  and  the  dose  was  de- 
creased to  75  grains  a  day.  Under  this  treatment  the  symp- 
toms ameliorated,  and  by  the  latter  part  of  September  the  pa- 
tient had  become  quite  strong  and  able  to  walk  freely,  although 
there  was  still  some  pain  in  the  arms  and  head.  In  October, 
treatment  with  small  doses  of  the  alteratives  was  continued, 
iodide  of  potassium  and  the  green  iodide  of  mercury  being 
used.  In  October  a  violent  headache  with  dizziness  came  on, 
but  was  relieved  by  blisters  back  of  the  ears,  leeches  to  the 
back  of  the  neck,  and  an  increase  of  the  iodides.  .  In  February 
of  1885  there  was  still  a  tendency  to  headache  after  study;  but 
#his  legs  seemed  entirely  well,  and  he  could  use  them  freely. 
The  patient's  condition  slowly  improved,  with  occasional  back- 
sets, and  in  November,  1887,  he  appeared  to  be  entirely  re- 
covered, and  was  able  to  run  and  jump  about  as  freely  as  ever. 
Subsequently  there  were  several  slight  relapses,  with  headache, 
weakness  of  the  legs,  etc.  Under  mild  but  persistent  anti- 
specific  medication,  the  health  of  the  patient  became  more 
thoroughly  established;  and  at  the  date  of  present  writing 
(March,  1889)  he  has  remained  for  many  months  entirely  free 
from  abnormal  manifestations,  and  able  to  do  a  very  large 
amount  of  work  in  his  profession. 

It  must  be  remembered  that  the  separation  of 


—  43  — 
these  varieties  of  cerebral  syphilis,  is  artificial  and 
arbitrary,  so  that  the  most  satisfactory  way  of  ap- 
proaching this  subject  is  to  study  the  important  symp- 
toms in  severalty,*  rather  than  to  attempt  to  group 
them  into  recognizable  varieties  of  the  disease;  and 
this  method  I  shall  here  adopt. 

Headache  is  the  most  constant,  and  usually  the 
earliest,  symptom  of  meningeal  syphilis;  but  it  may  be 
absent,  especially  when  the  lesion  is  located  in  the 
reflexions  of  the  meninges  which  dip  into  the  ventri- 
cles, or  when  the  basal  gumma  is  small  and  not  sur- 
rounded with  much  inflammation.  The  length  of 
time  it  may  continue  without  the  development  of  other 
distinct  symptoms,  is  remarkable.  In  one  case  *  at 
the  University  Dispensary,  the  patient  affirmed  that  he 
had  had  it  for  four  years  before  other  causes  of  com- 
plaint appeared.  It  sometimes  disappears  when  other 
symptoms  develop.  It  varies  almost  indefinitely  in 
its  type,  but  is,  except  in  very  rare  cases,  at  least  so 
far  paroxysmal  as  to  be  subject  to  pronounced  exacer- 
bations. In  most  instances  it  is  entirely  paroxysmal; 
and  a  curious  circumstance  is,  that  very  often  these 
paroxysms  may  occur  only  at  long  intervals.  Such  dis- 
tant paroxysms  are  usually  very  severe,  and  are  often 
accompanied  by  dizziness,  sick  stomach,  partial  un- 
consciousness, or  even  by  more  marked  congestive 
symptoms.     The  pain  may  seem  to  fill  the  whole  cra- 


*Book  Y,  p.  88,  1879. 


—  44  — 
nium,  may  be  located  in  a  cerebral  region,  or  fixed  in 
a  very  limited  spot.  Heubner  asserts  that  when  this 
headache  can  be  localized,  it  is  generally  made  dis- 
tinctly worse  by  pressure  at  certain  points;  but  my 
own  experience  is  hardly  in  accord  with  this.  Any 
such  soreness  plainly  cannot  directly  depend  upon  the 
cerebral  lesion.  In  the  great  majority  of  cases  I 
have  seen,  there  has  been  no  local  tenderness;  indeed, 
both  in  cerebral  and  spinal  syphilis,  according  to  my 
own  experience,  localized  soreness  indicates  an  affec- 
tion of  the  bone  or  of  its  periosteum.  In  many  cases, 
especially  when  the  headache  is  persistent,  there  are 
distinct  nocturnal  exacerbations. 

It  will  be  seen  that  there  is  nothing  absolutely 
characteristic  in  the  headache  of  cerebral  syphilis;  but 
excessive  persistency,  apparent  causelessness,  and  a 
tendency  to  nocturnal  exacerbation,  should  in  any 
cephalalgia  excite  suspicion  of  a  specific  origin — a 
suspicion  which  is  always  to  be  increased  by  the  oc- 
currence of  slight  spells  of  giddiness,  or  by  delirious 
mental  wandering  accompanying  the  paroxysms  of 
pain.  When  an  acute  inflammatory  attack  supervenes 
upon  a  specific  meningeal  disease,  it  is  usually  ushered 
in  by  a  headache  of  intolerable  severity. 

When  the  headache  in  any  case  is  habitually  very 
constant  and  severe,  the  disease  is  probably  in  the 
dura  mater  or  periosteum;  and  this  probability  is 
much  increased  if  the  pain  be  local  and  augmented 
by  firm,  hard  pressure  upon  the  skull  over  the  seat  of 
the  pain. 


—  45  — 

Disorders  of  Sleep. — There  are  two  antagonistic 
disorders  of  sleep,  either  of  which  may  occur  in  cere- 
bral syphilis,  but  which  have  only  been  present  in  a 
small  proportion  of  the  cases  that  I  have  seen.  In- 
somnia is  more  troublesome  in  the  prodromic  than  in 
the  later  stages,  and  is  only  of  significance  when  com- 
bined with  other  more  characteristic  symptoms.  A 
peculiar  somnolence  is  of  much  more  determinate  im- 
port. It  is  not  pathognomonic  of  cerebral  syphilis, 
yet  of  all  the  single  phenomena  of  this  disease  it  is 
the  most  characteristic.  Its  absence  is,  however,  of 
little  import  in  the  diagnosis  of  an  individual  case. 

As  I  have  seen  it,  it  occurs  in  two  forms.  In  the 
one  variety,  the  patient  sits  all  day  long,  or  lies  in  bed 
in  a  state  of  semi-stupor,  indifferent  to  everything, 
but  capable  of  being  aroused,  answering  questions 
slowly,  imperfectly,  and  without  complaint,  but  in  an 
instant  dropping  off  again  into  quietude.  In  the 
other  variety  the  sufferer  may  still  be  able  to  work, 
but  often  falls  asleep  while  at  his  tasks,  and  especially 
toward  evening  has  an  irresistible  desire  to  slumber, 
which  leads  him  to  pass,  it  may  be,  half  of  his  time  in 
sleep.  This  state  of  partial  sleep  may  precede  that  of 
the  more  continuous  stupor,  or  may  pass  off  when  an 
attack  of  hemiplegia  seems  to  divert  the  symptoms. 
The  mental  phenomena  in  the  more  severe  cases  of 
somnolency  are  peculiar.  The  patient  can  be  aroused 
— indeed,  in  many  instances  he  exists  in  a  state  of 
torpor  rather  than  of  sleep;  when  stirred  up  he  thinks 


—  46  — 

with  extreme  slowness,  and  may  appear  to  have  a 
form  of  aphasia;  yet  at  intervals  he  may  be  endowed 
with  a  peculiar  automatic  activity,  especially  at  night. 
— Getting  out  of  bed;  wandering  aimlessly  and  seem- 
ingly without  knowledge  of  where  he  is,  and  unable  to 
find  his  couch;  passing  his  excretions  in  a  corner  of 
the  room  or  in  other  similar  locality,  not  because  he 
is  unable  to  control  his  bladder  and  bowels,  but  be- 
cause he  believes  that  he  is  in  a  proper  place  for  such 
act — he  seems  a  restless  nocturnal  automaton  rather 
than  a  man.  In  some  cases  the  somnolent  patient  lies 
in  a  perpetual  stupor. 

Apathy  and  indifference  are  the  characteristics  of 
the  somnolent  state,  yet  the  patient  will  sometimes 
show  excessive  irritability  when  aroused,  and  will  at 
other  periods  complain  bitterly  of  pain  in  his  head,  or 
will  groan  as  though  suffering  severely  in  the  midst  of 
his  stupor — at  a  time,  too,  when  he  is  not  able  to  rec- 
ognize the  seat  of  the  pain.  I  have  seen  a  man  with 
vacant,  apathetic  face,  almost  complete  aphasia,  per- 
sistent heaviness  and  stupor,  arouse  himself  when  the 
stir  in  the  ward  told  him  that  the  attending  physician 
was  present,  and  come  forward  in  a  dazed,  highly 
pathetic  manner,  by  signs  and  broken  utterances  beg- 
ging for  something  to  relieve  his  head.  Huebner 
speaks  of  cases  in  which  the  irritability  was  such  that 
the  patient  fought  vigorously  when  aroused;  this  I 
have  not  seen. 

This  somnolent  condition  may  last  several  weeks. 


—  47  — 
T.  Buzzard*  details  the  case  of  a  man  who,  after  a 
specific  hemiplegia,  lay  silent  and  somnolent  for  a 
month,  and  yet  finally  recovered  so  completely  as  to 
win  a  rowing  match  on  the  Thames.  I  have  now  un- 
der my  care  a  patient  who  is  entirely  rational,  though 
he  still  suffers  from  occasional  uncontrollable  head- 
aches; who  several  years  since  was  profoundly  somno- 
lent for  four  months,  much  of  the  time  so  absolutely 
comatose  that  his  discharges  were  passed  in  his  bed 
without  his  knowledge,  and  his  food  swallowed  auto- 
matically when  put  into  his  mouth  by  a  nurse. 

In  its  excessive  development,  syphilitic  stupor  puts 
on  the  symptoms  of  advanced  brain-softening,  to  which 
it  is  indeed  often  due.  Of  the  two  cases  with  fatal  result 
which  I  have  notes,  one  at  the  autopsy  was  found  to 
have  symmetrical  purulent  breaking  down  of  the 
anterior  cerebral  lobes,  apparently  from  disease  of  the 
basal  arteries;  the  other,  softening  of  the  right  frontal 
and  temporal  lobes,  due  to  the  pressure  of  a  gum- 
matous tumor  and  ending  in  a  fatal  apoplexy. 

This  close  connection  with  cerebral  softening  ex- 
plains the  clinical  fact  that  apoplectic  hemorrhage  is 
apt  to  end  the  life  in  these  cases  of  somnolent 
syphilis.  But  a  prolonged  deep  stupor  in  persons 
suffering  from  cerebral  syphilis  does  not  prove  the  ex- 
istence of  extensive  brain-softening,  and  is  not  incom- 
patible with  subsequent  complete   recovery.      As  an 


*  Clinical  Lectures  on  Dis.  Nerv.  Sys.,  London,  1882. 


-  48  - 

element  of  prognosis,  it  is  of  serious  but  not  of  fatal 
import. 

Paralysis. — When  it  is  remembered  that  a  syphi- 
litic exudation  may  appear  at  almost  any  position  in 
the  brain,  that  spots  of  encephalic  softening  are  a  not 
rare  result  of  the  infection,  that  syphilitic  disease  is  one 
of  the  causes  of  cerebral  hemorrhage,  it  is  plain  that 
a  specific  palsy  may  be  of  any  conceivable  variety,  and 
affect  either  the  sensory,  motor,  or  intellectual  sphere. 
The  mode  of  onset  is  as  various  as  the  character  of 
the  palsy.  The  attack  may  be  instantaneous,  sudden, 
or  gradual.  The  gradual  development  of  the  syphi- 
litic gumma  would  lead  us,  a  priori,  to  expect  an 
equally  gradual  development  of  the  palsy;  but  experi- 
ence shows  that  in  a  large  proportion  of  the  cases  the 
paralysis  appears  suddenly,  with  or  without  the  occur- 
rence of  an  apoplectic  or  epileptic  fit.  Under  these 
circumstances  it  will  be  usually  noted  that  the  result- 
ing palsy  is  incomplete;  in  rare  instances  it  may  be  at 
its  worst  when  the  patient  awakes  from  the  apoplectic 
seizure;  but  commonly  it  progressively  increases  for  a 
few  hours  and  then  becomes  stationary.  These  sudden 
partial  palsies,  probably  result  from  an  intense  conges- 
tion around  the  seat  of  disease,  or  from  stoppage  of 
of  the  circulation  in  the  same  locality:  whatever  their 
mechanism  may  be,  it  is  important  to  distinguish  them 
from  palsies  which  are  due  to  hemorrhage.  I  believe 
this  can  usually  be  done  by  noting  the  degree  of  par- 
alysis. 


—  49  — 

A  suddenly-developed,  complete  hemiplegia,  or 
other  paralysis,  may  be  considered  as  in  all  probability 
either  hemorrhagic  or  produced  by  a  thrombus  so 
large  that  the  result  will  be  disorganization  of  the 
brain-substance,  and  a  future  no  more  hopeful  than 
that  of  a  clot.  On  the  other  hand,  an  incomplete 
palsy  may  be  rationally  believed  to  be  due  to  pressure 
or  other  removable  cause;  and  this  belief  is  much 
strengthened  by  a  gradual  development.  The  bear- 
ing of  these  facts  upon  prognosis  it  is  scarcely  neces- 
sary to  point  out. 

Although  the  gummata  may  develop  at  almost 
any  point,  they  especially  affect  the  base  of  the  brain, 
and  are  prone  to  involve  the  nerves  which  issue  from 
it.  Morbid  exudations,  not  tubercular  or  syphilitic, 
are  rare  in  this  region.  Hence  a  rapidly  but  not 
abruptly  appearing  strabismus,  ptosis,  dilated  pupil,  or 
any  paralytic  eye-symptom  in  the  adult,  is  usually  of  a 
syphilitic  nature.  Syphilitic  facial  palsy  is  not  so 
frequent,  whilst  paralysis  of  the  facial  nerve  from 
rheumatic  and  other  inflammation  within  its  bony 
canal,  is  very  common.  Paralysis  of  the  facial  nerve 
may  therefore  be  specific,  but  existing  alone  is  of  no 
diagnostic  value.  Since  syphilitic  palsies  about  the 
head  are  in  most  instances  due  to  pressure  upon  the 
nerve-trunks,  the  electrical  reactions  of  degeneration 
may  be  obtained  in  the  affected  muscles. 

There  is  one  peculiarity  about  specific  palsies 
which  has  already  been  alluded  to  as  frequently  pres- 

s  GG 


_   5o  — 

sent — namely,  their  temporary,  transient,  fugitive 
nature,  they  varying  in  character  and  seat.  Thus  an 
arm  may  be  weak  to-day,  strong  to-morrow,  and  the 
next  day  feeble  again,  or  the  recovered  arm  may  re- 
tain its  power  and  a  leg  fail  in  its  stead.  These 
transient  palsies  are  much  more  apt  to  involve  large 
than  small  brain  territories.  The  explanation  of  their 
largeness,  fugitiveness,  and  incompleteness  is  that 
they  are  not  directly  due  to  clots  or  other  structural 
changes,  but  to  congestions  of  the  brain-tissues  in  the 
neighborhood  of  gummatous  exudations.  Squint,  due 
to  direct  pressure  on  a  nerve,  will  remain  when  the 
accompanying  monoplegia  due  to  congestion  disap- 
pears. 

Motor  palsies  are  more  frequent  than  sensory 
affections  in  syphilis,  but  hemianaesthesia,  localized 
anaesthetic  tracts,  indeed  any  form  of  sensory  paraly- 
sis, may  occur.  Numbness,  formications,  all  varieties 
of  paresthesia,  are  frequently  felt  in  the  face,  body, 
or  extremities.  Violent  peripheral  neuralgic  pains  are 
rare,  and  generally  when  present  denote  neuritis. 
Huguenin,  however,  reports*  a  severe  trigeminal  an- 
aesthesia dolorosa,  which  was  found  after  death,  frqm 
intercurrent  disease,  to  have  depended  upon  a  small 
gumma  pressing  upon  the  Gasserian  ganglion.  A 
somewhat  similar  disease  has  been  reported  by  Allen 
McLane  Hamilton,  f 


*  Schwiez.  Corr.  Blat..  1875. 

f  Alienist  and  Neurologist,  iv,  58. 


—  51  — 
The  special  senses  are  liable  to  suffer  from  the 
invasion  of  their  territories  by  cerebral  syphilis,  and 
the  resulting  palsies  follow  courses,  and  have  clinical 
histories,  parallel  to  those  of  the  motor  sphere.  The 
onset  may  be  sudden  or  gradual,  the  result  temporary 
or  permanent.  Charles  Mauriac  *  reports  a  case  in 
which  the  patient  was  frequently  seized  with  sudden 
attacks  of  severe  frontal  pain  and  complete  blindness, 
lasting  from  a  quarter  to  half  an  hour;  at  other  times 
the  patient  had  spells  of  aphasia  lasting  for  one  or 
two  minutes.  I  have  seen  in  two  cases  nearly  com- 
plete deafness  develop  in  a  few  hours  in  cerebral 
syphilis,  and  disappear  abruptly  after  some  days. 
Like  other  syphilitic  palsies,  therefore,  paralysis  of 
special  senses  may  come  on  suddenly  or  gradually, 
and  may  occur  paroxysmally. 

Among  the  palsies  of  cerebral  syphilis  must  be 
ranked  aphasia.  An  examination  of  recorded  cases 
shows  that  syphilitic  aphasia  is  subject  to  vagaries  and 
laws  similar  to  those  which  dominate  other  specific 
cerebral  palsies.  It  is  usually  a  symptom  of  advanced 
disease,  but  may  certainly  develop  as  one  of  the  first 
evidences  of  cerebral  syphilis,  and  I  have  seen  it  as  the 
most  marked  symptom  in  an  acute  syphilitic  paroxysm 
when  no  distinct  history  of  prodromes  was  obtainable. 
Coming  on  after  an  apoplectic  or  epileptic  fit,  it  may 
be  complete  or  incomplete;  owing  to  the  smallness  of 


*  Loc.  Cit.,  p.  31. 


—  52  — 

the  centre  involved,  and  the  ease  with  which  its  func- 
tion is  held  in  abeyance,  a  total  loss  of  word-thought 
is  not  so  decisive  as  to  the  existence  of  cerebral  hemor- 
rhage as  is  a  total  motor  palsy.  Like  hemiplegia  or 
monoplegia,  specific  aphasia  is  sometimes  transitory 
and  paroxysmal.  Buzzard*  records  several  such  cases. 
Mauriacf  details  a  very  curious  case  in  which  a 
patient,  after  long  suffering  from  headache,  was  seized 
by  sudden  loss  of  power  in  the  right  hand  and  fingers, 
lasting  about  ten  minutes  only,  but  recurring  many 
times  a  day.  After  this  had  continued  some  time,  the 
paroxysms  became  more  completely  paralytic,  and 
were  accompanied  by  loss  of  the  power  of  finding 
words,  the  height  of  the  crises  in  the  palsy  and  aphasia 
being  simultaneously  reached.  For  a  whole  month, 
these  attacks  occurred  five  or  six  times  a  day,  without 
other  symptoms  except  headache,  and  then  the  patient 
became  persistently  paralytic  and  aphasic,  but  finally 
recovered.  To  describe  the  different  forms  of  specific 
aphasia  and  their  mechanism  of  production,  would  be 
to  enter  upon  a  discussion  of  aphasia  itself—  a  discus- 
sion out  of  place  here.  Suffice  it  to  say  that  any  con- 
ceivable form  of  aphasia  may  be  induced  by  syphilis, 
although  on  account  of  the  tendency  of  the  syphilitic 
lesion,  when  placed  near  the  speech  centres,  to  spread 
its  influence  over  a  wide  territory,  I   have   very  rarely 


*  Loc.  cit.,  p.  81. 

|  Aphasie  et  Hemiplegie  Droite  Syphilit.,  Paris,  1877. 


—  53  — 
been  able   to  detect   any  of  the   more  extraordinary 
forms  of  aphasia,  such  as  word-blindness,  etc. 

The  aphasia  may  be  the  result  of  a  gummatous 
tumor  involving  the  artery,  or  of  a  clot;  but  I  have 
seen  passing,  repeated,  attacks  of  complete  aphasia,  fol- 
lowed by  a  permanent  condition  of  partial  aphasia 
caused  by  syphilitic  degeneration  of  the  middle 
cerebral  artery,  as  proven  by  autopsy,  when  there  was 
no  localized  meningeal  gumma  present. 

Owing  to  the  centres  of  speech  being  situated  in 
the  cortical  portion  of  the  brain,  aphasia  in  cerebral 
syphilis  is  very  frequently  associated  with  epilepsy. 
Of  course  right-sided  palsy  and  aphasia  are  united  in 
syphilitic  as  in  other  disorders.  If,  however,  the 
statistics  given  by  Tanowsky*  be  reliable,  syphilitic 
aphasia  is  associated  with  left-sided  hemiplegia  in  an 
extraordinarily  large  proportion  of  cases.  Thus  in  53 
cases  collected  by  Tanowsky,  18  times  there  was  right- 
sided  hemiplegia,  and  14  times  left-sided  hemiplegia, 
the  other  cases  being  not  at  all  hemiplegic.  Judging 
from  the  autopsy  on  a  case  reported  in  Mauriac's 
brochure,  this  concurrence  of  left-sided  paralysis  and 
aphasia,  depends  partly  upon  the  great  frequency  of 
multiple  brain  lesions  in  syphilis,  and  partly  upon  the 
habitual  involvement  of  large  territories  of  the  gray 
matter  secondarily  to  diseased  membrane.  An  im- 
portant practical  deduction  is  that  the  conjoint  exist- 


L'Aphasie  Syphilitique. 


—  54  — 
ence  of  left  hemiplegia  and  aphasia  is  almost  diagnos- 
tic of  cerebral  syphilis. 

Probably  amongst  the  palsies  may  be  considered 
the  disturbances  of  the  renal  functions,  which  are  only 
rarely  met  with  in  cerebral  syphilis,  and  which  are 
probably  in  most  instances  dependent  upon  the  specific 
exudation  pressing  upon  the  vaso-motor  centres  in  the 
medulla.  Fournier  speaks  of  having  notes  of  six  cases 
in  which  polyuria  with  its  accompaniment,  polydipsia, 
was  present,  and  details  a  case  in  which  the  specific 
growth  was  found  in  the  floor  of  the  fourth  ventricle. 
Cases  have  been  reported  of  true  saccharine  diabetes 
due  to  cerebral  syphilis,*  and  I  can  add  to  these  an 
observation  of  my  own.  The  symptoms,  which 
occurred  in  a  man  of  middle  age  with  a  distinct 
specific  history,  were  headache,  nearly  complete  hemi- 
plegia, and  mental  failure,  associated  with  the  passage 
of  comparatively  small  quantities  of  urine  so  highly 
saccharine  as  to  be  really  a  syrup.  Under  the  influ- 
ence of  iodide  of  potassium,  the  sugar  in  a  few 
weeks  disappeared  from  the  urine. 

Epilepsy. — Epileptic  attacks  are  a  very  common 
symptom  of  meningeal  syphilis,  and  are  of  great  diag- 
nostic value.  The  occurrence  in  an  adult  of  an 
epileptic  fit,  after  a  history  of  intense  and  protracted 
headache,  should  always  excite  grave  suspicion. 


*  Consult  Servantie,  Des  Rapports  du  Diabete  et  de  la 
Syphilis,  Paris,  These,  1876;  also  case  reported  by  L.  Putzel, 
New  York  Med.  Record,  xxv,  450. 


—  55   ~ 

Before  I  had  read  Fournier's  work  on  Nervous 
Syphilis,  I  taught  that  an  epilepsy  appearing  after  thirty 
years  of  age  was  very  rarely,  if  ever  essential  epilepsy, 
and  unless  alcoholism,  uraemic  poison,  or  other 
adequate  cause  could  be  found,  was  in  nine  cases  out  of 
ten  specific;  and  I  therefore  quote  with  satisfaction 
Fournier's  words:  "  L'epilepsie  vraie,  ne  fait  jamais 
son  premier  debut  a  l'age  adulte,  a  l'age  mur.  Si  un 
homne  adulte,  au  dessus  de  30,  35,  a  40  ans,  vient,  a 
etre  pris  pour  la  premiere  fois  d'une  crise  epileptique, 
et  cela  dans  la  cours  d'une  bonne  sante  apparente,  il  y 
a,  je  vous  le  repete,  hui  ou  neuf  chances  sur  dix  pour 
que  cette  epilepsie  soit  d'originie  syphilitique." 

Syphilitic  epilepsy  may  occur  either  in  the  form 
of  petit  mal  or  of  haut  mal,  and  in  either  case  may 
take  on  the  exact  characters  and  sequence  of  phenom- 
ena which  belong  to  the  so-called  idiopathic  or  essen- 
tial epilepsy.  The  momentary  loss  of  consciousness 
of  petit  mal  will  usually,  however,  be  found  asso- 
ciated with  attacks  in  which,  although  voluntary  power 
is  suspended,  memory  recalls  what  has  happened 
during  the  paroxysm — attacks,  therefore,  which  simu- 
late those  of  hysteria,  and  which  may  lead  to  an  error 
of  diagnosis. 

Even  in  the  fully  developed  type  of  convul- 
sions, the  aura  is  only  rarely  present.  Its  absence  is 
not,  however,  of  diagnostic  value,  because  it  is  fre- 
quently not  present  in  essential  epilepsy,  and  it  may 
be  pronounced  in  the  specific  disease.      It  is  said  that 


-56  - 

when  in  an  individual  case  the  aura  has  once  appeared, 
the  same  type  or  form  of  approach  of  the  convulsion 
is  thereafter  rigidly  adhered  to.  The  aura  is  some- 
times bizarre:  a  severe  pain  in  the  foot,  a  localized 
cramp,  a  peculiar  sensation  indescribable  and  unreal 
in  its  feeling  may  be  the  first  warning  of  the  attack. 
Again,  an  aura  may  affect  a  special  sense:  thus,  I  had 
a  patient  whose  attacks  began  with  blindness.  When- 
ever, under  such  circumstances,  I  have  had  an  oppor- 
tunity of  making  a  post  mortem,  I  have  found  an 
organic  lesion  of  the  special  sense  centre  or  tract 
whose  function  had  been  disturbed  during  life. 

In  many,  perhaps  most,  cases  of  specific  convul- 
sions, instead  of  a  paroxysm  of  essential  epilepsy  be- 
ing closely  simulated,  the  movements  are  in  the  onset, 
or  more  rarely  throughout  the  paroxysm,  unilateral : 
indeed  they  may  be  confined  to  one  extremity.  This 
restriction  of  movement  has  been  held  to  be  almost 
characteristic  of  syphilitic  epilepsy,  but  it  is  not  so. 
Whatever  diagnostic  significance  such  restriction  of 
the  convulsion  has,  is  simply  to  indicate  that  the  fit 
is  due  to  cortical  organic  lesion  of  some  kind. 
Tumors,  scleroses,  and  other  organic  lesions  of  the 
brain-cortex  are  as  prone  to  cause  unilateral  or 
monoplegic  epilepsy  when  they  are  not  specific,  as 
when  they  are  due  to  syphilis.  Indeed  what  has 
here  been  said  in  regard  to  the  occurrence  of  aura, 
of  spasm,  or  of  paralysis,  applies  almost  as  equally 
well    to    other    organic    brain    diseases     as    syphilis. 


—  57  — 
Specific  and  non-specific  tumors  or  growths,  produce 
by   their   interference    with   the    function    of  a   part, 
similar  results. 

Sometimes  an  epilepsy  dependent  upon  a  specific 
lesion  implicating  the  brain-cortex,  may  be  replaced 
by  a  spasm  which  is  more  or  less  local,  and  is  not  at- 
tended with  any  loss  of  consciousness.  Thus,  in  a 
case  which  recovered  in  the  University  Hospital,  a 
man  aged  about  thirty-five,  offered  a  history  of  re- 
peated epileptic  convulsions,  but  at  the  time  of  his 
entrance  into  the  hospital,  instead  of  epileptic  attacks, 
there  was  a  painless  tic.  The  spasms,  which  were 
clonic,  and  occurred  very  many  times  a  day  (some- 
times every  five  minutes),  were  very  violent,  and  mostly 
confined  to  the  left  facial  nerve  distribution.  The 
trigeminus  was  never  affected,  but  in  the  severer  par- 
oxysms, the  left  hypoglossal  and  spinal  accessory 
nerves  were  profoundly  implicated  in  all  of  their 
branches.  Once,  fatal  asphyxia,  from  recurrent  laryn- 
geal spasm  of  the  glottis,  was  apparently  averted  only 
by  the  free  inhalation  of  nitrite  of  amyl.  The  sole 
other  symptom  was  headache;  but  the  specific  history 
was  clear,  and  the  effect  of  antisyphilitic  remedies 
rapid  and  pronounced. 

It  is  very  plain  that  such  attacks  as  those  just  de- 
tailed are  closely  allied  to  epilepsy.  Indeed,  there  are 
cases  of  cerebral  syphilis  in  which  wide  spread  gen- 
eral spasms  occur  similar  to  those  of  a  Jacksonian 
epilepsy,  excepting  in  that  consciousness  is  not  lost, 


—  58  — 

because  the  nervous  discharge  does  not  overwhelm  the 
centres  which  are  connected  with  consciousness.  (Case, 
Canada  Med.  and  Surg.  Joum ,  xi,  487).  On  the 
other  hand,  these  epileptoid  spasmodic  cases  link 
themselves  to  those  in  which  the  local  brain  affection 
manifests  itself  in  contractions  or  persistent  irregular 
clonic  or  tonic  spasms.  Contractures  may  exist,  and 
may  simulate  those  of  descending  degeneration  (case, 
Centrbl.  Nerv.  Heik.,  1883,  p.  1),  but  in  my  own  ex- 
perience are  very  rare.  A  case  of  syphilitic  athetosis 
maybe  found  in  the  Lancet,  1883,  ii,  989. 

The  clonic  spasms  of  cerebral  syphilis  may  assume 
a  distinctly  choreic  type,  or  may  in  their  severity  sim- 
ulate those  of  hysteria,  throwing  the  body  about  vio- 
lently. (See  Allison,  Amer.  Med.  Jour.,  1877,  74). 
It  is,  to  my  mind,  misleading,  and  therefore  improper, 
to  call  such  cases  syphilitic  chorea,  as  there  is  no  rea- 
son for  believing  that  they  have  a  direct  relation  with 
ordinary  chorea.  They  are  the  expression  of  an  or- 
ganic irritation  of  the  brain-cortex,  and  are  sometimes 
followed  by  paralysis  of  the  affected  member;  in  other 
words,  the  disease,  progressing  inward  from  the  brain 
membrane,  first  irritates,  and  then  so  invades  a  corti- 
cal centre  as  to  destroy  its  functional  power.  (Case, 
Chicago  Med.  Jour,  and  Exam.,  xlvi,  21). 

Psychical  Symptoms. — As  already  stated,  apathy, 
somnolence,  loss  of  memory,  and  general  mental 
failure,  are  the  most  frequent  and  characteristic  mental 
symptoms  of  meningeal  syphilis;  but,  as  will  be  shown 


—  59  — 
in  the  next  chapter,  syphilis  is  able  to  produce  almost 
any  form  of  insanity,  and  therefore  mania,  melan- 
cholia, erotic  mania,  delirium  of  grandeur,  etc.,  may 
develop  along  with  the  ordinary  manifestation  of  cere- 
bral syphilis,  or  may  come  on  during  an  attack  which 
previously  has  been  attended  by  only  the  usual  symp- 
toms. Without  attempting  any  exhaustive  citation  of 
cases,  the  following  may  be  alluded  to: 

A.  Erlenmeyer  *  reports  a  case  in  which  an  attack 
of  violent  headache  and  vomiting  was  followed  by 
paralysis  of  the  right  arm,  and  paresis  of  the  left  leg, 
with  some  mental  depression;  a  little  later  the  patient 
suddenly  became  very  cheerful,  and  shortly  afterward 
manifested  very  distinctly  delirium  of  grandeur  with 
failure  of  memory.  Batty  Tuke  \  reports  a  case  in 
which,  with  aphasia,  muscular  wasting,  strabismus,  and 
various  palsies,  there  were  delusions  and  hallucina- 
tions. S.  D.  Williams  J  records  a  case  in  which  there 
were  violent  paroxysmal  attacks  of  frontal  headache. 
The  woman  was  very  dirty  in  her  habits,  only  ate  when 
fed,  and  existed  in  a  state  of  hypochrondriacal  melan- 
choly. Leiderdorf  details  a  case  with  headache,  par- 
tial hemiplegia,  great  physical  disturbance,  irritability, 
change  of  character,  marked  delirum  of  grandeur, 
epileptic  attacks,  and  finally  dementia,  eventually 
cured  by  iodide   of  potassium.  |     Several  cases  illus- 

*  Die  Leutischen  Psychosen. 

f  Jour.  Ment.  Sci.,  Jan.  1874,  p.  560. 

%  Ibid,  April,   1869. 

||  Medicin.  Jahrbucher,  xx,  1864,  p.  214. 


—  6o  — 

trating  different  forms  of   insanity  are  reported  by  N. 
Manssurow.* 

That  the  attacks  of  syphilitic  insanity,  like  the 
palsies  of  syphilis,  may  at  times  be  temporary  and 
fugitive,  is  shown  by  a  curious  case  reported  by  H. 
Hayes  Newington,f  in  which,  along  with  headache, 
failure  of  memory,  and  ptosis,  in  a  syphilitic  person, 
there  was  a  brief  paroxysm  of  noisy  insanity. 

Syphilis  of  the  Brain  Cortex. 

The  mental  symptoms  which  are  produced  by 
syphilis  are  often  pronounced  when  paralysis,  head- 
ache, epilepsy,  or  other  palpable  manifestations  show 
the  presence  of  gross  gummatous  lesion.  In  pre- 
vious paragraphs  much  has  been  said  about  these  psy- 
chical disturbances,  but  it  seems  necessary  further  to 
discuss  the  question  whether  alienation  disturbances 
can  be  produced  by  syphilis  without  the  accompaniment 
of  headache,  or  other  evidences  of  the  presence  of  or- 
ganic disease,  and  whether  syphilis  is  capable  of  pro- 
ducing an  insanity  or  a  paralysis  except  by  causing  a 
distinctly  gummatous  lesion. 

According  to  our  present  nomenclature,  a  case  in 
which  psychical  disturbances  are  present  without  more 
definite  symptoms  of  organic  brain  disease,  is  properly 
spoken  of  as  one   of  insanity;  whereas  if  the  other 


*  Die  Tertiare  Syphilis,  Wien,  1877. 
f  Jour.  Ment.  Sci.,  London,  xix,  555. 


—  61   — 

organic  symptoms  are  present,  the  case  should  be 
spoken  of  as  one  of  gummatous  syphilis.  There  are  a 
few  alienists  who  recognize  the  existence  of  a  distinct 
form  of  insanity  properly  entitled  to  be  called  syphil- 
itic, and  there  are  others  who  deny  that  insanity  is 
ever  directly  caused  by  syphilis,  i.  <?.,  that  syphilis  can 
produce  mental  disturbance  without  causing  the  evi- 
dence of  an  organic  lesion.  It  is  certain  that  a  pure 
insanity  often  occurs  in  a  syphilitic  subject;  but  in  life, 
syphilis  is  very  frequently  joined  with  alcoholism, 
poverty,  mental  distress,  physical  ruin,  and  various 
depressing  emotions  and  conditions  which  are  well 
known  to  be  active  causes  of  mental  disorder.  It  may 
well  be  that  syphilis  may  co-act  with  these  causes;  or 
it  may  be  that  syphilis  may,  by  the  moral  depression 
which  it  produces,  become  an  indirect  cause  of  insanity; 
but  under  neither  of  these  sets  of  circumstances  could 
such  insanity  be  properly  spoken  of  as  syphilitic.. 

If  syphilis  can  produce  directly  disease  of  the 
brain  cortex,  such  disease  must  give  rise  to  mental 
disorder,  provided  it  is  properly  situated  and  suffi- 
ciently extensive.  Now  if  the  lesion  be  so  placed  that 
it  affects  the  psychic,  and  avoids  the  motor  and  sensory 
regions  of  the  brain,  it  will  produce  a  pure  insanity, 
i.  e.,  an  insanity  without  paralysis,  spasms,  headache, 
convulsions,  or  other  symptoms  of  organic  brain  dis- 
ease. Again,  if  such  a  brain  disease  be  wide  spread, 
involving  the  whole  cortex,  it  may  cause  a  progres- 
sive mental  disorder  accompanied  by  gradual  loss  of 


—    62    — 

muscular  power  in  all  portions  of  the  body,  ending 
in  dementia  with  general  paralysis;  or,  in  other  words, 
it  may  produce  an  affection  more  or  less  resembling 
the  so-called  general  paralysis  of  the  insane: 

Since  a  man  having  syphilis  may  have  a  disease 
which  is  not  directly  due  to  the  syphilis,  when  a  syph- 
ilitic person  has  any  disorder,  there  is  only  one  positive 
way  of  determining  during  life  how  far  said  disorder 
is  specific — namely,  by  studying  its  amenability  to 
antisyphilitic  treatment.  In  approaching  the  question 
whether  a  lesion  found  after  death  is  specific  or  not, 
of  course  such  a  therapeutic  test  as  that  just  given  is 
inapplicable.  We  can  only  study  as  to  the  coexist- 
ence of  the  lesion  with  other  lesions  known  to  be 
specific.  Such  coexistence,  of  course,  does  not  ab- 
solutely prove  the  specific  nature  of  a  nutritive  change, 
but  renders  such  nature  exceedingly  probable. 

What  has  just  been  said  foreshadows  the  method 
in  which  the  subject  in  hand  is  to  be  here  examined, 
and  the  present  article  naturally  divides  itself  into  two 
sections — the  first  considering  the  coexistence  of  ana- 
tomical alterations  occurring  in  the  cerebral  substance 
with  syphilitic  affections  of  the  brain-membranes  or 
blood-vessels,  the  second  being  a  clinical  study  of 
syphilitic  insanity. 

In  looking  over  the  literature  of  the  subject  I 
have  found  the  following  cases  in  which  a  cerebral 
sclerotic  affection  coincided  with  a  gummatous  disease 
of  the  membrane. 


-  63  - 

Gros  and  Lancereaux,*  report  a  case  having  a 
clear  syphilitic  history  in  which  the  dura  mater  was 
adherent  to  the  skull.  The  pia  mater  was  not  adher- 
ent. Beneath,  upon  the  vault  of  the  brain,  was  a 
gelatinous  exudation.  The  upper  cerebral  substance 
was  indurated,  and  pronounced  by  Robin,  after  micro- 
scopic examination,  to  be  sclerosed.  At  the  base  of 
the  brain  there  were  atheromatous  arteries  and  spots 
of  marked  softening. 

Joseph  J.  Brownf  reports  a  case  in  which  the 
symptoms  were,  melancholia,  excessive  irritability,  vio- 
lent outbursts  of  temper,  very  positive  delusions,  dis- 
ordered gait,  ending  in  dementia.  At  the  autopsy, 
which  was  very  exhaustive,  extensive  syphilitic  disease 
of  the  vessels  of  the  brain  and  spinal  cord  was  found. 
The  pia  mater  was  not  adherent  to  the  brain.  The 
convolutions,  particularly  of  the  frontal  and  parietal 
lobes,  were  atrophied,  with  very  wide  sulci  filled  with 
bloody  serum.  The  neuroglia  of  these  convolutions 
was  much  increased,  and  "  appeared  to  be  more  mole- 
cular than  normal;  the  cells  had  degenerated,  and  in 
many  places  had  disappeared,  their  places  being  only 
occupied  by  some  granules,"  These  changes  were 
most  marked  in  the  frontal  convolutions. 

H.  SchuleJ  reports  a  very  carefully  and  meritori- 


*Affec.  Nerv.  Syphilis,  1861,  p.  245. 

f  Allgem    Zeitschrtft  f.  Psychiatrie,  xxviii,  171-2. 

\  Journ.  Ment.  Sci.,  July,  1875  p.  271. 


-  64  - 

ously  studied  case.  The  symptoms  during  life  exactly 
simulated  those  of  dementia  paralytica.  The  affection 
commenced  with  an  entire  change  in  the  disposition  of 
the  patient;  from  being  taciturn,  quiet,  and  very  par- 
simonious, he  became  very  excited,  restless,  and  desir- 
ed continuously  to  buy  in  the  shops.  Then  failure  of 
memory,  marked  sense  of  well-being,  carelessness  and 
indifference  for  the  future,  developed  consentaneously 
with  failure  of  the  power  of  walking,  trembling  of  the 
hands,  inequality  of  the  pupils,  and  hesitating  speech. 
There  was  next  a  period  of  melancholy,  which  was  in 
time  followed  by  continuous  failure  of  mental  and 
motor  powers,  and  very  pronounced  delirium  of 
grandeur,  ending  in  complete  dementia.  Death 
finally  occurred  from  universal  palsy,  with  progressive 
increase  of  the  motor  symptoms.  At  the  autopsy 
characteristic  syphilitic  lesions  were  found  in  the 
skull,  dura  mater,  larynx,  liver,  intestines,  and 
testicles.  The  brain  presented  the  macroscopic  and 
microscopic  characters  of  sclerosis  and  atrophy;  the 
neuroglia  was  much  increased,  full  of  numerous 
nuclei;  the  ganglion-cells  destroyed.  The  vessels 
were  very  much  diseased,  some  reduced  to  cords; 
their  walls  were  greatly  thickened,  and  full  of  long 
spindle-shaped  cells,  sometimes  also  containing  fatty 
granules. 

C.  E.  Stedman  and  Robt.  T.  Edes,  report*  a  case 
in  which  the  symptoms  were,  failure  of  health,   ptosis, 

*  American  Journ.  Med.  Sciences,  lxix,  433. 


-  65  - 

trigeminal  palsy  with  pain  (anaesthesia  dolorosa), 
and  finally  mental  failure  with  gradual  loss  of  power  of 
motion  and  sensation.  At  the  autopsy  the  following 
conditions  were  noted:  apex  of  the  temporal  lobe  ad- 
herent to  dura  mater  and  softened;  exuded  lymph  in 
neighborhood  of  optic  chiasm;  sclerosis  of  right  Gasse- 
rian  ganglion,  as  shown  in  a  marked  increase  of  the  neu- 
roglia; degeneration  of  the  basal  arteries  of  the  brain. 

These  cases  are  sufficient  to  demonstrate  that  sclero- 
sis of  the  brain- substance  not  only  may  co-exist  with  a 
brain  lesion  which  is  certainly  specific  in  its  character, 
but  may  also  present  the  appearance  of  having  develop- 
ed part  passu  with  that  lesion,  and  from  the  same  cause. 

It  has  already  been  stated  in  this  article  that 
cerebral  meningeal  syphilis  may  coexist  with  various 
forms  of  insanity,  and  cases  have  been  cited  in  proof 
thereof.  It  is  of  course  very  probable  that  in  some  of 
such  cases  there  has  been  that  double  lesion  of  mem- 
brane and  gray  brain  matter  which  has  just  been  de- 
monstrated from  the  records  of  autopsies;  but  if  we  find 
that  there  is  syphilitic  insanity,  which  exists  without 
evidences  of  meningeal  syphilis,  and  is  capable  of  be- 
ing cured  by  antispecific  treatment,  such  insanity  must 
be  considered  as  representing  the  disease  of  the  gray 
matter  of  the  brain.  Medical  literature  is  so  gigantic 
that  it  is  impossible  to  exhaust  it,  but  the  following 
list  of  cases  is  amply  sufficient  to  prove  the  point  at 
issue — namely,  that  there  is  a  syphilitic  insanity  which 
exists  without  obvious  meningeal  disease,  and  is 
capable  of  being  cured  by  antisyphilitic  treatment: 

6   GG 


66 


REPORTER  AND  JOURNAL. 


Louis  Streisand 

Die  Lues  als  Ursache  der 
Dementia,  Inaug  Diss., 
Berlin,  1878. 

Ibid 

Miiller  of  Luetkirch  . 

Journ.    of  Mental    Dis., 

1873-74.  S61 ■ 
Esmarch  and  W.  Jersen 

A  llgem .      Ze  itsch  rift    /. 

Psyckiatrie . 
Leidesdorf . 

Medizin.Jahrbucher,  xx., 

1864,  1. 
Beauregard 

Gaz.  hebdoni.  de  Sci.  me'd 

de  Bordeaux,  1880,  p.  64. 
M.  Rendu 

Ibid. 


M .  Rendu 

Gaz.he~bdom.de  Sci.  me'd. 

de  Bordeaux,  1880,  p.  64. 
Albrecht  Erlenmeyer 

Die  Luetischen  Psychosen, 

Neuwied,  1877. 
Ibid 


Ibid. 


Ibid. 


Ibid. 


SYMPTOMS. 


Epilepsy,  delirium  of  exaltation,  alter- 
ation of  speech,  headache,  failure  of 
memory. 

Delusions,  delirium,  general  mania,  great 
muscular  weakness. 

Symptoms  resembling  general  paralysis, 
and  diagnosis  of  such  made  until  a 
sternal  node  was  discovered . 

Sleeplessness,  great  excitement,  restless- 
ness, great  activity,  incoherence,  and 
violence. 

Complete  mania;  played  with  his  excre- 
ment, and  entirely  irrational 

Symptoms  resembling  those  of  general 
paralysis . 

Loss  of  memory,  headache,  irregularity 
of  pupils,  ambitious  delirium,  periods 
of  excitement,  others  of  depression,  em- 
barassment  of  speech,  access  of  furious 
delirium,  ending:  in  stupor. 

Hypochondria,  irregularity  of  pupils, 
headache,  failure  of  memory,  melan- 
choly, stupor. 

Melancholia  with  hypochondriasis,  sleep- 
lessness, fear  of  men,  and  belief  they 
were  all  leagued  against  him. 

Religious  melancholia,  with  two  attempts 
at  suicide,  ending  in  mania. 

At  times  very  violent,  yelling,  shrieking, 
destroying  everything  she  could  get 
hands  on;  at  times  erotomania;  no  dis- 
tinct history  of  infection,  but  her 
habits  known  to  be  bad,  and  had  bone 
ozcena  and  other  physical  syphilitic 
signs. 

Epileptic  attack  followed  by  a  long 
soporose  condition,  ending  in  mental 
confusion,  he  not  knowing  his  nearest 
friends,  etc.;  almost  dementia. 

Great  fear  ot  gendarmes,  etc.,  mania, 
with  hallucinations,  loud  crying,  yell- 
ing, etc.,  then  convulsion,  followed  by 
great  difficulty  of  speech. 


RESULTS. — REMARKS. 


Rapid  cure  with  mercury. 


Cure  with  mercury. 

Cure  by  iodide   of  potas- 
sium. 

Cure  by  mercury. 


Complete  cure  by  iodide  of 
potassium. 

Cure    by    iodide   of  potas- 
sium. 

Mercurial  treatment,  cure. 


Mercurial  treatment,  cure. 

Iodide  of  potassium,  cure. 

Iodide  of  potassium,  cure. 
Iodide  of  potassium,  cure. 


Cured  by  mercurial  inunc- 
tion. 


Cured  by  mercurial  inunc. 
tions  with  iodide  inter- 
nally ;  subsequently  re- 
turn of  convulsions,  fol- 
lowed by  hemiplegie  and 
death. 


67 


REPORTER  AND  JOURNAL. 


A .  Erlenmeyer  ... 
Die  Lu'etischen,  etc. 


Ibid 

Relapse  of  Case  14 . 


A .  Erlenmeyer 

Die  Luetischen,  etc 

Ibid 

Ibid. 

Ibid 

Ibid 


J.  B.  Chapin 

Amer.  Journ.  Insanity, 
vol.  xv,  p.  249 

Ibid 

Snel 

Wm.  Smith        

Brit.  Med.  Journ.,  July. 
1868,  p. 


SYMPTOMS. 


Great  unnatural  vivacity  and  loquacity, 
wanted  to  buy  everything,  bragged  of 
enormous  gains  at  play,  etc.;  some  trou- 
ble of  speech. 

Fifteen  months  after  discharge  from 
asylum  relapse;  symptoms  developing 
very  rapidly,  delirium  of  grandeur  of 
the  most  aggravated  type,  with  marked 
progressive  dementia,  failure  of  power 
of  speech,  and  finally  of  locomotion. 

Failure  of  mental  powers,  inequality  of 
pupils,  trembling  of  lip  when  speaking, 
uncertainty  of  gait,  almost  entire  loss 
memory,  once  temporary  ptosis  and 
strabismus . 

Failure  of  mental  power,  pronounced 
delirium  of  grandeur,  hallucinations  of 
hearing,  failure  of  memory,  strabismus 
and  ptosis  coming  on  late. 

Failure  of  memory  and  mental  powers, 
slight  ideas  of  grandeur,  disturbance  of 
sensibility  and  motility,  aphasia  com- 
ing on  late. 

Melancholy,  great  excitability,  ideas  of 
grandeur;  after  a  long  time  sudden 
ptosis  and  strabismus. 

Various  cerebral  nerve  palsies,  great  re- 
lief by  use  of  mercurial  inunctions,  then 
development  of  great  excitement,  de- 
lirium of  grandeur,  failure  of  memory 
and  mental  powers,  and  finally  death 
from  apoplexy;  no  autopsy. 

Melancholia  with  attempted  suicide,  epi- 
lepsy, headache,  somnolent  spells. 

Acute    mania,    noisy,  very    destructive; 

syphilitic  disease  of  tibia. 
Maniacal  excitement. 

Apathetic  melancholy,  indelicate,  speak- 
ing only  in  monosyllables,  and  much  of 
the  time  not  at  all,  sullen  and  menac- 
ing. 


RESULTS. — REMARKS. 


Iodide  of  potassium,  cure. 
Attended  to  business, 
and  seemed  as  well  a9 
before.  Relapse.  (See 
Symptoms.) 

Failure  of  various  anti- 
specific  treatments. 


Iodide  of  potassium  in  as- 
cending doses  failed.  Re- 
covery under  mercurial 
inunctions. 

Iodide  of  potassium,  corro- 
sive-sublimate injections. 
Cure. 

Cure  with  use  of  iodide 
and  mercurial  inunctions. 


Iodide  of  potassium  failed; 
mercurial  course  im- 
proved ;  joint  use  cured 
patient. 


Iodide  of  potassium,  cure. 

Iodide  of  potassium,  cure. 

Cured  by  specific  treat- 
ment. 

Rapidly  cured  by  conjoint 
use  of  iodide  and  mer- 
curials. The  symptoms 
first  developed  3  months 
after  chancre. 


—  68  — 

A  study  of  the  brief  analyses  of  the  symptoms 
just  given  shows  that  syphilitic  disease  of  the  brain 
may  cause  any  form  of  mania,  but  that  the  symptoms, 
however  varied  they  may  be  at  first,  unless  relieved, 
end  almost  always  in  dementia. 

Of  all  the  forms  of  insanity,  general  paralysis 
is  most  closely  and  frequently  simulated  by  specific 
brain  disease.  The  exact  relation  of  the  diathesis 
to  true,  incurable,  general  paralysis,  is  very 
difficult  to  determine.  It  seems  well  established 
that  amongst  persons  suffering  from  this  disorder,  the 
proportion  of  syphilitics  is  not  only  much  larger  than 
normal,  but  also  much  larger  than  in  other  forms  of 
insanity.  Thus,  E.  Mendel*  found  that  in  146  cases 
of  general  paralysis,  109,  or  75  per  cent.,  had  a  dis- 
tinct history  of  syphilis,  whilst  in  101  cases  of  various 
other  forms  of  primary  insanity,  only  18  per  cent,  had 
specific  antecedents.  H.  Obersteiner  had  in  1000  cases 
of  mental  disease,!  175  cases  of  dementia  paralytica; 
of  these,  21.6  per  cent,  had  syphilis;  moreover,  of  all 
the  syphilitic  patients  51.4  per  cent,  had  dementia 
paralytica. 

Various  opinions  might  be  cited  as  to  the  nature 
of  this  relation  between  the  two  disorders,  but  for 
want  of  space,  the  curious  reader  is  referred  to  the 
work  just  quoted,  and  to  the  thesis  of  C.  Chauvet,]; 

*  Progres.  Paral.  der  Irren,  Berlin,  1880. 
f  Monatshefte  f.  prakt.  Dermat,  Dec,  1882. 
%  Influence  de  la  Syph.  sur  les   Malad.  du  Syst.  Nerveux, 
Paris,  1880. 


_  69  - 
for  an  epitome  of  the  most  important  recorded  opin- 
ions. 

Those  who  suffer  from  syphilis  are  exposed  in 
much  greater  proportion  than  are  other  persons  to  the 
ill  effects  of  intemperance,  sexual  excesses,  poverty, 
mental  agony,  and  other  well-established  causes  of 
general  paralysis.  It  may  be  that  in  this  is  sufficient 
explanation  of  the  frequency  of  general  paralysis  in 
syphilitics,  but  I  incline  to  the  belief  that  syphilis  has 
some  direct  effect  in  producing  the  disease.  How- 
ever this  may  be,  I  think  we  must  recognize  as  estab- 
lished the  opinion  of  Voisin,*  that  there  is  a  syphilitic 
peri-encephalitis  which  presents  symptoms  closely  re- 
sembling those  of  general  paralysis.  Such  cases  are 
examples  of  the  pseudo-paralysie  ginerale  of  Four- 
nier.f 

The  question  as  to  the  diagnosis  of  these  cases 
from  the  true  incurable  paresis  is,  of  course,  very  im- 
portant, and  has  been  considered  at  great  length  by 
Voisin,J  Fournier,§  and  Mickel.*| 

The  points  which  have  been  relied  upon  as  diag- 
nostic of  syphilitic  pseudo-general  paralysis  are: 

The  occurrence  of  headache,  worse  at  night  and 
present  amongst  the  prodromes;  an   early  persistent 


*  Paralysie  generale  des  Alienes,  1S79. 

f  La  Syphilis  du  Cerveau,  Paris,  1879. 

%  Loc.  cit. 

§  Loc.  cit. 

*[  Brit,  and  For.  Med.-Chir.  Review,  1877, 


—  7Q  — 

insomnia  or  somnolence;  early  epileptiform  attacks, 
the  exaltation  being  less  marked,  less  persistent,  and 
perhaps  less  associated  with  general  maniacal  restless- 
ness and  excitement,  the  articulation  being  paralytic 
rather  than  paretic;  the  absence  of  tremulousness, 
especially  of  the  upper  lip  (Fournier) ;  the  effect  of 
antispecific  remedies. 

When  the  conditions  in  any  case  correspond  with 
the  characters  just  paragraphed,  or  when  any  of  the 
distinguishing  characteristics  of  brain  syphilis,  as  pre- 
viously given,  are  present,  the  probability  is  that  the 
disorder  is  specific  and  remediable.  But  the  absence 
of  these  marks  of  specific  disease  is  not  proof  that  the 
patient  is  not  suffering  from  syphilis.  Headache  may 
be  absent  in  cerebral  syphilis,  as  also  may  insomnia 
and  somnolence.  Epileptiform  attacks  are  not  always 
present  in  the  pseudo-paralysis,  and  may  be  present 
in  the  genuine  affection;  a  review  of  the  cases  previ- 
ously tabulated  shows  that  in  several  of  them  the 
megalomania  was  most  pronounced;  and  a  case  with 
very  pronounced  delirium  of  grandeur,  in  which  the 
autopsy  revealed  unquestionably  specific  brain  lesions, 
may  be  found  in  Chauvet's  Thesis,  p.  31. 

Case  14  of  the  table  is  exceedingly  interesting, 
because  it  seems  to  represent,  as  successively  occur- 
ring in  one  individual,  both  pseudo  and  true  general 
paralysis.  The  symptoms  of  general  paralysis  in  a 
syphilitic  subject  disappeared  under  the  use  of  mer- 
cury, to  recur  some  months  afterward  with  increased 


—  7i   — 

violence,  and  with  new  obstinency  that  resisted  with 
complete  success  antisyphilitic  treatment.  I  have  my- 
self seen  cases  in  which  the  symptoms  of  general  par- 
alysis existed  in  persons  with  a  syphilitic  history,  but 
in  which  all  of  the  differences  supposed  by  Voisin, 
Fournier  and  Mickle  to  be  diagnostic,  failed,  except- 
ing only  the  therapeutic  test,  i.  e.,  the  effect  of  the 
iodide  of  potassium;  in  such  cases  an  immediate  diag- 
nosis was  simply  impossible,  and  great  caution  is 
needed  in  interpreting  the  therapeutic  test,  since  very 
frequently  true  general  paralysis  occurs  in  syphilitic 
subjects;  the  non-production  of  iodism  in  such  a  case 
is  a  ground  for  hope,  but  unless  with  the  toleration 
there  is  soon  distinct  improvement,  the  hope  is  prone 
to  be  a  delusive  one. 

It  must  be  considered,  as  at  present  established,  that 
syphilis  may  produce  a  disorder  whose  symptoms  do  not 
apparently  differ  from  those  of  general  paralysis;  that 
true  general  paralysis  is  very  frequent  in  the  syphilitic; 
that  the  curable  cortical  affection  producing  the  symp- 
toms of  true  general  paralysis  may  change  into,  or  be 
followed  by,  an  incurable  form  of  the  disease,  and 
that,  therefore,  it  is  the  duty  of  the  practitioner  in  a 
case  presenting  symptoms  of  general  paralysis,  to  use 
a  treatment  of  antisyphilitic  remedies,  unless  there  be 
an  absolutely  clear  history  of  freedom  from  syphilitic 
taint.  That  cortical  disease,  apparently  syphilitic, 
may  exist  along  with  widespread  degeneration  of  the 
vessels,  but  without  distinct  gummatous  disease,  and 


—  72  — 

give  rise  to  symptoms  which  are  not  distinctly  differ- 
ent from  those  of  some  cases  of  general  paralysis  as  is 
proven  by  the  following  case  of  which  I  subjoin  the 
clinical  record  with  the  results  obtained  by  post 
mortem  examination: 

Mr.  R.  M.  M.  came  first  under  my  care  March  2,  1888, 
with  a  history  that  some  years  since  he  had  acquired  syphilis 
from  a  woman  who  came  to  an  interior  town,  and  who, 
in  the  course  of  a  very  short  time,  infected  fifteen  boys,  seven  of 
whom  are  now  dead.  He  had  various  constitutional  disturb- 
ances, and  had  been  having  obscure  nervous  symptoms.  He 
stated  that  he  had  had  some  little  pain  in  the  head,  but  that  it 
had  never  been  severe;  there  was  also  a  clear  history  of  his 
having  had  spells,  lasting  several  days,  of  apathy  and  som- 
nolence; no  failure  of  memory,  however,  could  be  detected, 
and  he  was  still  attending  to  his  business  as  a  clerk.  There 
was  no  paralysis  or  ocular  symptoms,  but  there  was  a  very 
marked  slowness  and  thickness  of  speech,  and  an  evident  loss 
of  quickness  in  intellectual  action.  He  was  put  upon  anti- 
specific  treatment,  both  iodide  and  mercury  being  used.  In 
the  latter  part  of  May  he  was  taken  acutely  ill  with  delirum, 
great  restlessness,  and  partial  aphasia.  Mercury  was  freely 
exhibited,  and  after  the  appearance  of  ptyalism,  he  rapidly 
grew  better,  and  in  about  two  weeks  was  able  to  come  to  my 
office.  Under  the  continued  used  of  the  iodide  of  potassium 
and  mercury,  he  steadily  improved,  and  when  I  left  Philadel- 
phia in  the  middle  of  July,  recovery  apparently  was  not  far 
from  complete. 

During  the  summer  he  is  represented  as  having  been  in 
good  condition,  but  in  the  latter  portion  of  September  he  had 
an  acute  attack,  and  was  admitted  September,  28,  1888,  to  the 
University  Hospital.  It  was  noted  that  day  "that  the  pupils 
were  equally  dilated,  and  responded,   though  somewhat   slug- 


—  73  — 

gishly  to  light;  that  the  knee  jerk  was  exaggerated,  but  that 
there  was  no  ancle  clomus;  that  there  was  no  loss  of  sensation; 
that  intellection  was  exceedingly  imperfect;  that  there  was 
great,  almost  delirious,  restlessness,  and  partial  aphasia,  the 
patient  answering  many  questions — 'Yes'  and  'Yes,'  sir — 
without  respect  to  the  nature  of  the  interrogation,  although 
he  was  able  to  use  a  number  of  words  intelligently."  It  was 
exceedingly  difficult  to  make  him  understand  at  all  what  was 
wanted,  and  it  was  impossible  to  obtain  satisfactory  results  in 
testing  for  sensory  aphasia. 

Under  protracted  treatment,  there  was  some,  but  not  very 
great  improvement  in  Mr.  M.'s  condition,  but  in  the  latter  part 
of  October  his  aphasia  rather  rapidly  increased,  and  his  rest- 
lessness became  more  pronounced  and  was  accompanied  by 
delirious  wakefulness  at  night.  Whilst  under  immediate  ob- 
servation, on  October  24th,  his  right  hand  in  a  few  minutes 
became  (but  not  completely)  paralyzed,  without  disorder  of 
sensation.  On  getting  him  to  bed  it  was  found  that  his  gait 
was  very  ataxic,  and  that  the  right  leg  distinctly  dragged; 
when  walking  there  was  a  marked  tendency  to  go  toward 
the  left.  The  attack  had  been  preceded  by  complaint  of  pain 
in  the  head  on  the  left  side,  but  the  nurse's  attention  was  first 
called  by  noticing  that  the  man  was  violently  rubbing  his  right 
fingers,  and  swearing.  She  found  that  the  arm  and  hand  were 
both  stiff,  but  in  a  little  while  the  little  finger  became  limber, 
as  did  the  other  fingers,  successively,  a  little  later.  After  the 
first  few  minutes  the  partial  hemiplegia  did  not  increase. 

Mr.  M.  again  improved  under  treatment,  and  on  the  13th 
of  November,  was  brought  to  my  office.  He,  at  this  time, 
had  not  sufficient  intellectual  power  to  go  about  the  city 
by  himself.  He  was  very  wakeful  at  night,  having  a  distinct 
tendency  to  wander  about,  and  to  get  up  frequently  to  go  down 
stairs,  so  that  he  had  to  be  watched.  His  sister  asserted  that 
at  home  he  recognized  objects,  so  that  she  could  send  him  for 


—  74  — 

the  scissors  and  thread;  but,  under  examination  at  the  office, 
it  was  exceedingly  difficult  to  make  him  do  what  he  was  told, 
or  to  get  him  to  recognize  the  most  ordinary  objects.  He 
evidently  had  some  ideas,  and  with  a  great  deal  of  effort  made 
me  understand  that  he  was  "  nervous  to-day,  and  could  not  do 
as  well  as  common."  Most  of  the  time  his  talk  was  gibberish, 
but  occasionally  he  would  get  out  a  few  words  conveying 
sense.  He  was  handed  a  printed  form  commencing  with  my 
name;  the  name  he  pronounced  correctly,  but  after  it,  all  he 
said  was  gibberish,  no  word  being  so  spoken  that  it  could  be 
understood.  He  wrote  his  own  name  in  a  book  legibly;  but 
when  told  to  write  the  word  "cat,"  wrote  "rats."  When  the 
pen  was  out  of  ink,  he  could  not  be  made  to  understand  that 
he  was  to  dip  it  into  the  ink- stand;  but  when  it  was  refilled 
with  ink,  he  went  on  writing.  After  writing  three  or  four 
words,  he  seemed  to  lose  all  control  over  himself,  and  was 
unable  to  do  more.     At  this  time  there  was  no  paralysis. 

About  one  week  later,  Mr.  M.  was  taken  with  mild  de- 
lirium and  restlessness,  accompanied  by  slight  hemiplegia. 
This  lasted  two  or  three  da\s,  and  was  followed  by  return  to 
his  previous  state.  Shortly  after  this,  he  had  an  attack  of 
right-sided  hemiplegia,  more  pronounced  than  any  previous, 
but  not  affecting  the  face,  and  not  accompanied  with  delirious 
excitement  as  had  been  all  his  earlier  attacks.  Under  treat- 
ment he  recovered  from  this,  and  was  able,  on  December  12, 
to  report  at  my  office.  His  pupils  at  this  time  were  very 
mobile,  his  knee  jerks  very  active,  and  his  power  of  thought 
and  speech  greater  than  at  the  previous  visits.  He  recognized 
what  scissors  were  used  for,  and  cut  with  them;  called  knife 
and  keys  by  their  right  names,  but  also  called  scissors  "  keys." 
During  the  next  two  weeks  he  was  much  of  the  time  very  rest- 
less, spending  hours  packing:  his  valise,  insisting  that  he  was 
going  away;  very  excitable,  especially  at  night,  and  without 
pronounced  change  in  his  aphasia.     December  15th,  he  had  a 


—  75  — 
slight  convulsive  attack  in  the  morning.  December  29th, 
when  thought  by  his  friends  to  be  better,  he  was  suddenly 
taken  with  violent  choreic  movements  of  the  right  arm,  affect- 
ing sometimes  the  shoulder,  sometimes  only  the  forearm  and 
fingers,  accompanied  by  complete  loss  of  consciousness.  After 
this  Mr.  M.  never  recovered  consciousness;  the  choreic  move- 
ments continued,  but  grew  more  feeble  and  at  last  ceased; 
motor  power  slowly  failed  in  all  parts  ot  the  body,  and  death 
occurred  after  ten  days  of  automatic  existence. 

Autopsy,  fourteen  hours  after  death;  head  only  examined. 
The  base  of  the  brain  was  normal,  but  the  arteries  had  under- 
gone great  change,  and  to  the  naked  eye  appeared  to  be  in  an 
advanced   state   of  atheroma.      A   well-formed   thrombus   ex- 
tended  far  up   into   each   middle  cerebral  artery;  on  the  right 
side  this  thrombus  was  very  white,  and  apparently  much  older 
than  the  soft  red  thrombus  on  the  left  side.     On   the   upper 
surface  of  the  brain,  the  arachnoid  and  pia  mater  were  every- 
where  very  much  agglutinated  and  slightly   thickened      The 
change  was  especially  marked  over  the  anterior  portions  of  the 
brain,    where   the   membranes   were   so    adherent    that    they 
could'  not  be  separated  without  being  torn  to  pieces.     No  local- 
ized lesions  were  discovered,  except  that  there  was  some  soft- 
ening of  the  island  of  Reil  on  the  left  side.     Careful  examina- 
tion   failed    to   detect   the    presence   of    gummatous   tumors, 
sclerotic  scars,  or  other  evidence  of  focal  lesions  in  the  brain, 
either  present  or  past,  save  only  the  softening  just  spoken  of. 
Microscopic  examination  of  the  anterior  lobes  of  the  brain, 
in  which  the  diseased   process  had  gone  to  its  fullest  extent, 
showed   the    blood-vessels    and    capillaries,    from  the  largest 
to   the  smallest,  everywhere   gorged   with   blood,  their  walls 
enormously  thickened,  and  all  the  coats,  excepting  the  endo- 
thelum,  participating  in  the  change.     The  perivascular   spaces 
were  in  many  places  enlarged,  in  some  places  apparently  oblit- 
erated.     In   the   walls   of  the   blood-vessels,    and   especially 


_  76  - 

exterior  to  them  in  the  brain  cortex  were  everywhere  numbers 
of  small  cells,  which  in  some  places  were  collected  into  minute 
masses;  in  the  pia  mater  these  cells  were  more  abundant  than 
in  the  brain  substance  itself,  and  in  a  few  places  were  collected 
in  masses  of  considerable  extent — never,  however,  into  such 
isolated  and  well  marked  aggregation  as  could  properly  be  called 
even  a  minute  gummatous  mass.  The  whole  cortical  substance 
was  filled  with  small  cells  or  large  nuclei  similar  to  those  de- 
scribed, and  evidently  of  similar  nature  to  them;  nerve  cells 
and  nerve  tubules  in  the  most  affected  regions  entirely  gone, 
no  trace  of  them  apparent,  unless  some  of  the  round  nuclei 
just  spoken  of  were  the  remains  of  shrunken  and  altered  nerve 
c«lls. 

In  the  posterior  lobes  of  the  brain,  where  the  pia  mater  was 
not  adherent,  the  nerve  cells  were  perfectly  preserved,  and  the 
neuroglia  not  excessively  abundant;  but  the  coats  of  the  ves- 
sels, even  in  the  small  capillaries,  were  thickly  studded,  or  even 
covered  over,  with  the  same  small  cells  as  described  above — 
and  in  some  places  there  was  found  even  small  masses  of  these 
cells  about  the  blood-vessels,  The  perivascular  spaces  were 
very  large  in  this  portion  of  the  brain,  and  very  clear.  It  was 
noted,  also,  that  the  changes  of  the  vessel  were  fully  as 
marked,  or  even  more  marked,  in  the  brain  substance  than  in 
the  pia  mater. 

Section  III.     Diagnosis. 

In  a  diagnosis  of  cerebral  syphilis,  a  correct  his- 
tory of  the  antecedents  of  the  patient  is  of  vital  im- 
portance. Since  very  few  of  the  first  manifestations 
of  the  disorder  are  absolutely  characteristic,  whilst 
almost  any  conceivable  cerebral  symptoms  may  arise 
from  syphilitic  disease,  treatment  should  be  at  once 


—  77  — 
instituted  on  the  appearance  of  any  disturbance  of  the 
cerebral  functions  in  an  infected  person. 

Very  frequently  the  history  of  the  case  is  defec- 
tive, and  not  rarely  actually  misleading.  Patients  often 
appear  to  have  no  suspicion  of  the  nature  of  their 
complaint,  and  will  deny  the  possibility  of  syphilis,  al- 
though they  confess  to  habitual  unchastity.  My  own 
inquiries  have  been  so  often  misleading  in  their  results 
that  I  attach  but  little  weight  to  the  statements  of  the 
patient,  and  in  private  practice  avoid  asking  questions 
which  might  recall  unpleasant  memories,  depending 
upon  the  symptoms  themselves  for  the  diagnosis. 

In  discussing  the  diagnostic  value  of  the  various 
symptoms  of  cerebral  syphilis,  it  has  seemed  to  me 
that  the  clearest  view  of  the  matter  can  be  obtained 
by  considering  first  the  more  acute,  and  secondly  the 
more  chronic  forms  of  the  disease. 

The  symptoms  of  an  acute  syphilitic  brain  attack 
may  closely  simulate  those  of  epilepsy,  of  apoplexy  or 
of  acute  inflammation  of  the  brain  or  its  membranes.  . 
Under  these  circumstances  the  diagnosis  may  be  diffi- 
cult, and  may  depend  upon  the  acuteness  of  the  phy- 
sician in  discovering,  by  cross-examination  of  the 
friends  of  the  patient,  the  prodromic  manifestations 
which  had  passed  by  unnoted  or  unappreciated.  These 
prodromes  are  especially  worthy  of  very  close  study, 
not  only  on  account  of  their  value  in  the  recognition 
of  the  nature  of  an  acute  brain  syphilis,  but  because 
in  chronic  brain  syphilis  they  may  presage  an  acute 


-78- 

attack,  and  thus  enable  the  practitioner  to  ward  off 
what  otherwise  might  prove  a  fatal  exacerbation. 

Peristent  headache,  slight  failure  of  memory,  un- 
wonted slowness  of  speech,  general  lassitude,  and  lack 
of  willingness  to  mental  exertion,  sleeplessness  or  ex- 
cessive somnolence,  attacks  of  momentary  giddiness, 
vertiginous  feelings  when  straining  at  stool,  yelling,  or 
in  any  way  disturbing  the  cerebral  circulation,  altera- 
tion of  disposition,  any  of  these — and  a  fortiori  several 
of  them — occurring  in  a  syphilitic  subject,  should  be 
the  immediate  signal  for  alarm.  Of  these  varied  pos- 
sible prodromic  symptoms,  the  most  important  and 
characteristic,  according  to  my  experience,  are  head- 
ache, and  somnolence;  slight  and  shifting  localized 
weaknesses  sometimes  precede  an  acute  attack,  but  are 
more  characteristic  of  the  disease  at  a  later  stage.  A 
momentary  weakness  of  one  arm;  a  slight  drawing  of 
the  face,  disappearing  in  a  few  hours;  a  temporary 
dragging  of  the  toes;  a  partial  aphasia  which  appears 
.  and  reappears;  a  squint  which  to-morrow  leaves  no 
trace;  all  or  any  of  these  may  be  due  to  a  non-specific 
brain  tumor,  to  miliary  cerebral  aneurisms,  or  to  some 
other  non-specific  affection,  but  in  the  majority  of 
cases  when  these  phenomena  occur  repeatedly  in  a 
patient  who  is  not  suffering  from  hysteria,  they  are 
the  result  of  syphilis. 

In  private  practice,  instances  are  comparatively 
rare  in  which  it  is  not  possible  to  obtain  any  history 
of  prodromes  indicating  the  true  nature  of  a  sudden 


—  79  — 
violent  syphilitic  attack,  which  mimicks  apoplexy  or 
other  acute  organic  brain  disease.  In  hospital  practice 
it  is,  however,  otherwise.  I  have  frequently  seen  cases 
of  brain  syphilis  picked  up  in  the  streets  by  the  police, 
or  sent  in  by  physicians,  with  the  simple  statement 
that  the  patient  had  suffered  from  apoplexy,  a  sun- 
stroke, a  fall  from  a  cart  or  flat,  an  epileptic  fit,  or 
other  acute  accident  or  disease.  Fortunately,  the 
primary  treatment  of  an  acute  brain  congestion  the 
result  of  syphilis,  is  similar  to  the  treatment  of  a  simi- 
lar condition  from  other  causes;  but  it  is  all-important 
that  the  true  nature  of  the  disease  be  made  out  in  the 
course  of  a  few  hours. 

In  studying  such  a  case,  the  presence  or  absence 
of  Bright's  disease,  of  general  arterial  atheroma,  and 
of  traumatism,  must  first  be  determined  on  account  of 
the  close  connection  of  these  affections  or  accidents 
with  organic  brain  disease  not  syphilitic.  Pronounced 
disturbance  of  the  temperature  is  frequent  in  hemi- 
plegic  apoplexy,  very  rare  in  syphilitic  attacks;  its 
presence  is  therefore  of  diagnostic  import,  although  its 
absence  is  of  comparatively  little  value  as  a  guide. 
Complete  hemiplegia,  and  conjugate  deviation  of  the 
head  and  eyes,  are  common  apoplectic  symptoms, 
which  if  ever  present  in  syphilitic  attacks  are  ex- 
tremely rare.  The  presence  in  any  individual  case  of 
decided  ocular  palsy  not  accompanied  with  hemiplegia, 
of  partial  hemiplegia,  of  partial  loss  of  conscious- 
ness,   of   spasmodic  contraction    of   the     muscles    of 


—  8o  — 

the  back  of  the  neck,  of  any  cortical  localizing  symp- 
tom, or  of  spasms  tonic  or  clonic  in  moderate  sized 
groups  of  voluntary  muscles  of  the  body,  should  al- 
ways very  strongly  arouse  suspicion.  Under  these 
circumstances,  a  careful  examination  of  the  person  of 
the  patient  will  often  reveal  cicatrical  marks,  primary 
or  secondary  alterations  of  structure,  or  tenderness  of 
the  tibia  or  of  the  sternum  *  sufficiently  marked  to  be 
recognized  even  in  a  condition  of  partial  unconscious- 
ness. 

The  age  of  the  patient  must  also  be  taken  into 
consideration.  Apoplexy  occurs  most  frequently  in 
persons  over  fifty  years  of  age,  while  congestive  syph- 
ilitic attacks  are  most  common  before  that  age.  The 
course  of  a  case  for  the  first  six  or  ten  hours  after  the 
commencement  of  the  acute  paroxysm,  is  sufficiently 
different  in  the  two  affections  to  be  worthy  of  the 
closest  study.  A  hemiplegic  or  embolic  apoplexy 
which  is  sufficiently  severe  to  keep  up  pronounced  dis- 
turbance of  consciousness  for  some  hours,  is  almost  in- 
variably accompanied  by  a  complete  hemiplegia,  or 
more  rarely  by  some  other  palsy  which  is  complete; 
whilst  in  the  syphilitic  attack  it  is  rare  for  the  paralysis 
to  be  complete,  and  frequently  it  is  altogether  wanting. 
I  believe  myself,  that  a  complete,  suddenly  developed 


*  I  desire  especially   to  direct  attention   to  the  effect    of 
firm  pressure  over  the  sternum,  as  not  rarely  eliciting  distinct 
evidences  of  a  tenderness  which  is  almost  pathognomonic  o 
syphilis. 


hemiplegia,  or  other  wide  spread  palsy,  even  when  oc- 
curring in  a  syphilitic  patient,  is  almost  invariably  the 
result  of  hemorrhage  or  of  thrombosis.  Unless  the 
clot  has  been  a  very  large  one,  the  return  to  conscious- 
ness after  hemorrhagic  apoplexy  is  usually  much  more 
rapid  than  it  ordinarily  is  in  syphilitic  cases.  Head- 
ache after  an  apoplexy  is  rare,  whilst  headache  is  very 
frequent  after  a  severe  syphilitic  congestive  attack. 

In  any  individual  case,  the  diagnosis  is  greatly 
strengthened  by  the  presence  of  evidences  of  irritation 
of  the  base  of  the  brain,  such  as  ocular  palsies  or 
ocular  spasms,  or  spasms  of  the  neck  or  of  the  face. 
In  many  of  these  cases  of  syphilis,  it  is  not  possible 
at  first  to  make  an  absolutely  positive  diagnosis,  but 
the  experienced  practitioner  ought  to  be  rarely  at 
fault  in  his  management  of  the  case.  A  probable 
diagnosis  can  usually  be  made,  and  when  there  are 
any  distinct  grounds  for  supposing  that  the  case  is 
one  of  syphilis,  antispecific  treatment  should  be  at 
once  resorted  to,  since  it  can  do  no  harm  in  a  case  of 
true  apoplexy,  and  may  be  the  means  of  saving  life 
in  the  syphilitic  mimicry  of  that  disorder. 

In  rare  cases  of  acute  syphilis,  the  attack  takes 
on  itself  some  peculiar  form.  Under  these  circum- 
stances, the  mere  strangeness  and  irregularity  of  the 
symptoms  should  arouse  the  physician's  suspicion, 
as  there  is  nothing  more  typical  of  brain  syphilis  than 
the  failure  of  the  symptoms  to  conform  to  ordinary 
types   of   organic  brain  disease.     As  an   instance   of 


—    82    — 

such  an  attack  may  be  stated  the  case  reported  by  J. 
A.  Omerod  (Brain,  vol.  v,  260)  in  which  a  man  who 
had  been  in  good  health,  save  only  that  he  had  suf- 
fered from  headache,  awoke  one  morning  in  a  semi- 
delirious  condition,  then  went  to  sleep,  and  slept 
for  three  days  steadily,  arousing  only  when  fed.  After 
this  somnolence  there  was  impairment  in  memory  and 
mental  faculties,  but  no  marked  symptoms. 

The  general  grounds  of  diagnosis  in  chronic  brain 
syphilis  have  been  sufficiently  mapped  out  in  the  sec- 
tion devoted  to  symptomatology,  but  some  reiteration 
may  be  allowable. 

It  must  be  remembered  that  the  symptoms  of 
cerebral  syphilis  are  those  of  organic  brain  disease, 
and  that  any  peculiarity  they  may  possess  is  due  to 
the  fact  that  syphilitic  lesions  are  prone  to  be 
multiple  or  widespread,  to  be  situated  in  peculiar 
locations,  and  to  be  rapidly  developed  at  an  age  when 
other  organic  brain  diseases  are  rare.  The  cerebral 
cortex  with  its  separated  centres  is  especially  prone 
to  be  invaded,  hence  complete  hemiplegia  is  very  rare, 
whilst  multiple,  local,  or  partial  palsies  are  frequent; 
the  base  of  the  brain  is  more  frequently  attacked, 
hence  symptoms  of  basal  chronic  meningitis  occurring 
in  non-tubercular  adults  are  usually  the  outcome 
of  syphilis;  on  the  other  hand,  the  occipital  lobes  are 
rarely  affected,  hence  homonymous  hemianopsia  is 
uncommon. 

Headache   occurring   with   any   form   of    ocular 


-83- 

palsy  or  with  a  history  of  attack  of  partial  monoplegia 
or  hemiplegia,  vertigo,  petit  mat,  epileptoid  convul- 
sions, or  disturbances  of  consciousness,  or  attacks  of 
unilateral  or  localized  spasms,  should  lead  to  the  practi- 
cal therapeutic  test.  Ocular  palsies,  epileptic  forms 
of  attacks  occurring  after  thirty  years  of  age,  morbid 
somnolence  even  when  existing  alone,  are  sufficient 
to  put  the  practitioner  upon  his  guard.  It  is  some- 
times of  vital  importance  that  the  nature  of  the 
cephalalgia  shall  be  recognized  before  the  coming  on 
of  more  serious  symptoms;  any  apparent  causeless- 
ness,  severity,  and  persistency,  should  arouse  suspicion, 
to  be  much  increased  by  a  tendency  to  nocturnal  ex- 
acerbations, or  by  the  occurrence  of  mental  disturb- 
ance or  of  giddiness  at  the  crises  of  the  paroxysms. 
Not  rarely  there  are  very  early  in  these  cases,  curious 
almost  indefinable,  disturbances  of  cerebral  functions 
which  may  be  easily  overlooked,  such  as  temporary 
and  partial  failure  of  memory,  word-stumbling,  fleet- 
ing feelings  of  numbness  or  weakness,  and  alterations  of 
disposition.  In  the  absence  of  hysteria,  an  indefinite 
and  apparently  disconnected  series  of  nerve  accidents 
is  of  very  urgent  import.  To  use  the  words  of  Hugh- 
lings- Jackson,  "  A  random  association,  or  a  random 
succession,  of  nervous  symptoms,  is  very  strong  war- 
rant for  a  diagnosis  of  syphilitic  disease  of  the  ner- 
vous system."  Cerebral  syphilis  occurring  in  an  hys- 
terical subject,  may  be  readily  overlooked  until  fatal 
mischief  is  done.     When  any  paralysis  occurs,  a  study 


—  84  - 

of  the  reflexes  may  sometimes  lead  to  a  correct  diag- 
nosis. Thus,  in  syphilitic  hemiplegia,  the  reflex  on  the 
affected  side  is  very  frequently  exaggerated,  whilst  in 
hysterical  hemiplegia  the  reflexes  are  usually  alike  on 
both  sides.  When  both  motion  and  sensation  are  dis- 
turbed in  an  organic  hemiplegia,  the  anaesthesia  and 
motor  paralysis  occur  on  the  same  side  of  the  body, 
whilst  in  hysteria  they  are  usually  on  opposite  srdes. 

In  his  recent  lectures  upon  the  subject,  Prof.  Gowers 
attaches  a  great  deal  of  importance  to  the  rate  of  de- 
velopment of  optic  neuritis  in  the  diagnosis  of  syphilis. 
He  correctly  states  that  a  rapid  growth  never  causes  a 
chronic  form  of  neuritis,  although  now  and  then  a 
slow  growth  may  cause  an  acute  form.  From  this  he 
reasons  that,  while  acuteness  of  the  neuritis  is  of  little 
diagnostic  value,  chronicity — a  neuritis  that  remains 
for  a  long  time  moderate  or  slight  in  degree — is  dis- 
tinctly opposed  to  the  diagnosis  of  a  syphilitic  growth, 
and  adds  considerable  weight  to  the  similar  indication 
afforded  by  great  chronicity  of  other  symptoms.  This 
indication,  he  thinks,  is  especially  valuable  when  the 
early  symptoms  are  equivocal,  and  we  find  it  difficult 
to  say  how  long  the  tumor  has  existed. 

Although  great  weight  necessarily  attaches  to  the 
dictum  of  Prof.  Gowers,  in  my  own  experience  very 
rarely  has  the  diagnosis  been  aided  by  a  study  of  the 
rate  of  development  of  an  optic  neuritis.  I  am  fully 
convinced  that  frequently  the  syphilitic  growth  is  (and 
remains  for  a  long  time)  very  small  in  extent,  and 


_  85   - 

does  not  produce  optic  neuritis  at  all;  and  that  where 
the  specific  brain  lesion  is  more  extensive,  the  syphil- 
omatous  inflammation  does  not  necessarily  spread 
rapidly.  Also,  unfortunately,  the  choked  disk,  or  the 
consequent  atrophy,  are  but  too  often  established 
before  the  case  comes  into  the  practitioner's  hands,  so 
that  it  is  impossible  to  determine  how  slow  or  how 
rapid  the  first  changes  have  been. 

The  diagnosis  of  cerebral  syphilis  during  life,  is 
always  a  matter  of  inference.  Only  after  autopsy  can 
we  say  with  a  positive  certainty  that  the  individual  has 
suffered  from  specific  disorder  of  the  brain  or  its  mem- 
branes. Rapidly  developed  glioma,  and  rachitic,  tuber- 
cular or  other  meningitic  inflammation,  may  simulate 
a  syphilitic  lesion.  Moreover,  I  know  of  no  evidence 
showing  that  syphilis  protects  its  victim  from  the  de- 
velopment of  a  non-specific  brain  lesion. 

In  the  diagnosis  of  cerebral  syphilis  during  life, 
the  nearest  approach  to  certainty  that  we  can  arrive 
at  is  in  those  cases  in  which  the  patient  has  presented 
the  symptoms  of  cerebral  syphilis,  and  has  recovered 
under  distinct  antisyphilitic  treatment.  For  therapeu- 
tic purposes  a  probable  diagnosis  is  all  that  is  re- 
quired, and  hence  the  value  of  the  so-called  therapeu- 
tic test. 

It  has  been  denied  (see  Therapeutic  Gazette  for 
December,  1888,  and  March,  1889)  that  syphilis  in 
any  way  protects  against  the  action  of  the  iodide  of 
potassium,  or    that  there   is   any  value  in  the   thear- 


—   86   — 

peutic  test.  But  I  must  insist  that  in  nerve  syphilis 
there  is  usually  an  extraordinary  tolerance  of  the 
iodide,  so  that  almost  all  such  syphilitic  subjects  will 
bear  doses  of  20  grains  and  over,  frequently  repeated. 
It  is,  indeed  true,  that  there  are  a  few  persons  suffer- 
ing from  undoubted  syphilis  in  whom  this  tolerance 
does  not  exist,  but  such  patients  are  exceptional. 
There  are  a  very  few  healthy  persons  who  can  take 
the  iodide  at  once  in  large  doses  without  serious  incon- 
venience; and  there  is  a  still  more  numerous  class  in 
whom  tolerance  of  the  iodide  can  be  established  by 
commencing  with  small  doses  and  gradually  increas- 
ing. The  vast  majority,  however,  of  persons  who 
are  .free  from  syphilitic  affection,  cannot  take 
doses  of  over  10  grains  of  the  iodide  three  times  a 
day  without  the  production  of  iodism,  except  as  the 
result  of  the  habitual  use  of  the  remedy.  When  iodides 
are  tolerated  by  the  normal  individual,  such  individual 
is  said  to  have  an  idiosyncrasy,  which  makes  him  an 
exception  to  the  general  rule.  In  syphilitics  this  rule 
is  reversed,  and  when  the  person  suffering  from  syph- 
ilis cannot  endure  iodides,  the  lack  of  tolerance  is 
owing  to  an  idiosyncrasy — i.  e.,  the  individual  is  an 
exception  to  the  general  rule.  The  number  of  excep- 
tions to  the  rule  in  either  case  is  so  small  that,  for  the 
purposes  of  practical  medicine,  when  we  find  that  a 
person  can  tolerate  large  doses  of  the  iodides,  the 
probabilities  that  such  person  is  suffering  from  syph- 
ilitic infection  are  so  strong  as  to  warrant  the  tenta- 


—  ac- 
tive diagnosis  of  syphilis  if  the  tolerance  of  the  iodide 
be  accompanied  by  the  presence  of  symptoms  of   or- 
ganic nerve  disease  not  readily  explainable. 

In  the  comparatively  few  cases  of  primary  and 
early  secondary  syphilis  which  I  have  had  to  treat,  I 
have  found  that  a  very  considerable  proportion  of  the 
patients  will  not  bear  the  use  of  the  iodides,  and  I 
believe  that  the  tolerance  of  the  iodides  belongs  to  the 
advanced,  rather  than  the  early,  stages  of  the  disorder. 

The  converse  of  the  opinion  which  was  given  a 
few  lines  back,  does  not  hold  with  as  much  force  upon 
the  practitioner  as  does  the  proposition  itself.  The 
production  of  iodism  by  small  doses  of  the  drug  is, 
however,  evidence  {not  proof)  that  the  patient  is  not 
suffering  from  syphilitic  disorder,  and  in  any  given 
case  renders  it  probable  that  the  symptoms  are  not 
the  result  of  syphilitic  affection.  It  is,  however,  in 
practice,  essential  to  remember  that  there  are  excep- 
tions to  the  general  rule,  and  that  whenever  there  is  a 
clear  history  of  infection,  and  the  symptoms  trend 
towards  specific  disease,  trials  of  other  forms  of  anti- 
specific  medication  should  be  made  before  the  final 
working  opinion  is  formed.  Thus,  last  spring,  I  saw 
a  gentleman  from  a  distant  city  in  whom,  in  middle 
life,  epileptic  convulsions  had  developed  with  mental 
failure,  evidences  of  ocular  paralysis,  headache,  and 
great  depression  of  the  general  health,  and  in  whom 
there  was  a  clear  history  of  chancre.  He  could  not 
tolerate  iodide  of  potassium  at  all;  even  small  doses 


caused  great  gastric  disturbance.  The  careful  use  of 
mercurials,  followed  by  the  employment  of  the  iodide 
in  very  small  doses,  restored  the  patient  to  health. 

Section  III.     Prognosis. 

The  ebb  and  flow  of  the  currents  of  life  and 
death  in  meningeal  syphilis,  vary  so  greatly  and  so 
unexpectedly,  that  practitioners  of  the  largest  ex- 
perience may  well  hesitate  in  their  forecasts  of  the 
future  of  the  case  before  them.  In  practice  two  dis- 
tict  classes  of  opinions  are  asked  for.  In  an  acute 
attack,  the  question  is  as  to  recovery  from  the  in- 
dividual attack.  Here  the  general  laws  of  prognosis 
in  acute  brain  disease  hold  to  some  extent,  but  must 
always  be  favorably  modified,  and  unless  the  occur- 
rence of  a  complete  hemiplegia  or  moneplegia,  or  of 
conjugate  deviation  of  the  head  and  eyes,  or  marked 
rise  of  temperature,  indicate  the  presence  of  a  clot  or 
thrombus,  the  chances  always  are  strongly  in  favor  of 
recovery.  I  have,  however,  seen  death  occur  during 
simple  epileptic  convulsions  in  two  cases  of  brain 
syphilis.  The  arrest  of  respiration  which  is  so  com- 
mon in  the  attacks,  continued  too  long  for  life  to  be 
restored.  On  the  other  hand  I  have  repeatedly  seen 
patients  who  were  unconscious,  with  urinary  and  faecal 
incontinence,  and  absolute  relaxation  of  their  whole 
muscular  system,  and  who  indeed  were  apparently 
dying,  recover. 

The   prognosis   of    an   acute    primary  attack  of 


-  89  - 

cerebral  congestion  or  inflammation  of  specific  origin  is 
on  the  whole  favorable,  although  it  should  be  somewhat 
guarded.  Moreover  in  such  a  case,  so  long  as  there  is 
life,  a  positively  hopeless  prognosis  is  not  justifiable. 
In  chronic  syphilis,  the  prognosis  should  be  favorable, 
unless  there  be  reasons  for  supposing  that  there  is 
absolute  destruction  of  brain  tissue,  or  unless  the  pa- 
tient has  failed  to  respond  favorably  to  antisyphilitic 
treatment.  With  growing  experience,  however,  has 
come,  in  my  own  case,  growing  caution  in  predicting 
as  to  the  future. 

At  one  time  it  was  my  habit  to  give  a  very  favor- 
able prognosis  in  any  individual  case  so  soon  as  I  was 
sure  of  the  tolerance  of  the  iodide.  I  now  know  that 
it  is  possible  for  a  syphilitic  patient  to  tolerate  the 
iodides  in  indefinite  doses,  and  yet  to  obtain  no  relief 
from  their  use.  A  favorable  prognosis  ought  not, 
therefore,  to  be  based  upon  the  simple  tolerance  of  the 
drug;  but  when  along  with  such  tolerance  the  symp- 
toms soon  begin  to  rapidly  ameliorate,  there  is  always 
good  grounds  for  predicting  a  more  or  less  complete 
recovery. 

Even  under  the  most  hopeful  circumstances,  how- 
ever, we  are  liable  to  be  cruelly  disappointed,  so  that, 
although  encouragement  should  be  given,  and  the 
probabilities  of  recovery  be  stated,  at  least  to  the 
friends  of  the  patient  we  should  express  the  possibili- 
ties of  unsuspected  disaster. 

The  causes  why  the  iodides  may  be  tolerated  by 


—  9°  — 
the   syphilitic  person,  suffering  from  organic  nervous 
disease,  and  yet  afford  no  relief,  are  several. 

In  the  first  place,  there  is  a  class  of  cases  in  which 
the  primary  lesion  is  in  the  blood-vessels,  and  we  have 
no  sufficient  ground  for  believing  that  a  syphilitic 
arterial  degeneration,  which  is  at  all  advanced,  is 
capable  of  being  cured  by  treatment. 

In  the  second  place  it  is  not  always  possible  to 
distinguish  between  a  gummatous  curable  syphilis,  and 
an  incurable  syphilitic-meningeo-encephalitis.  I  have 
seen  very  numerous  cases  in  which  sclerosis  of  the 
nerve-centres  has  been  present  in  syphilitic  persons 
who  were  tolerant  of  the  iodides  but  had  not  been 
benefited  by  their  use. 

In  the  third  place,  a  gummatous  tumor  may  itself 
be  entirely  subordinate  to  the  iodides,  and  yet  have 
set  up  by  pressure  a  lesion  of  the  surrounding  nerve- 
centre  which  is  not  controllable  by  any  specific  medi- 
cation, so  that  symptoms  of  organic  brain-disease  may 
continue  after  the  removal  of  the  gumma.  A  case  in 
which  I  had  an  opportunity  to  make  the  autopsy  illus- 
trates this  point  well.  In  a  man  who  had  long 
suffered  from  cerebral  syphilis,  under  the  influence  of 
the  large  doses  of  the  iodides  and  of  mercurials, 
the  symptoms  had  all  disappeared,  except  that  at 
irregular  intervals  epileptic  convulsious  recurred,  and 
were  not  controlled  by  long-continued,  and  very  care- 
ful, specific  medication.  In  one  of  these  convulsions 
the  man  died,  and,  after  death,  in  the  cerebral  cortex 


—  9l  — 

a  small  patch  of  sclerosis  was  discovered,  evidently  a 
scar,  marking  the  former  site  of  a  gumma. 

Section  IV.     Treatment. 
The  treatment  of  cerebral  syphilis  is  best  studied 
under  two   heads:       First,  the  treatment    of   the  ac- 
cidents which   occur   in  the    course   of   the^  disease; 
second,  the  general  treatment  of  the  disease  itself. 

It  must  be  remembered  that  in,  perhaps,  the  ma- 
jority of  cases  in  which  death  occurs  in  properly-treated 
cerebral  syphilis,  the  fatal  result  is  produced  by  an  ex- 
acerbation—or, as  I  have  termed   it,   an  accident— of 
the  disease.      Under  these  circumstances  the  treat- 
ment should  be  that  which  is  adapted  to  the  relief  of 
the  same  acute  affection  when  dependent  upon  other 
than  specific  cause.     In  a  large  proportion  of  cases 
the  acute  outbreak  takes  the  form  either  of  a  menin- 
gitis or  else  of  a  brain  congestion.    In  either  instance, 
when  the  symptoms  are   severe   and    attended  with 
pronounced  arterial  excitement,  free  bleeding  should 
be  at  once  resorted  to.     The  amount  of  blood  taken 
is,  of  course,  to  be  proportionate  to  the  severity  of  the 
symptoms  and  the  strength  of  the   patient.      I   have 
seen  life  saved  by  the  abstraction  of  about  a  quart  of 
blood,    whilst   in    other   cases   a   few   ounces   suffice. 
Care  must,  of  course,  be  taken  not  to  mistake  a  simple 
epileptic  fit,  one  of   a  series   of  recurrent  paroxysms, 
for  a  severe  cerebral  attack;  but  even  when  the  fit  is  a 
simple  epileptic  convulsion,  if  it  has  been  preceded  by 


—  92  — 

severe  headache  and  is  accompanied  by  stupor,  with 
marked  disturbance  of  the  respiration,  measures  for 
immediate  relief  are  usually  required.  Further,  if  the 
epileptic  status  exists  and  the  convulsions  be  perpetu- 
ally repeated,  or  if  there  be  violent  delirious  excite- 
ment, the  symptoms  may  be  considered  as  very 
urgent.  In  taking  blood,  the  orifice  should  be  large 
so  as  to  favor  a  rapid  flow,  and  the  bleeding  be  con- 
tinued until  a  distinct  impression  is  made  upon  the 
pulse.  In  cases  in  which  the  action  of  the  heart  has 
continued  to  be  violent  after  as  much  blood  as  was 
deemed  prudent  had  been  taken,  I  have  seen  good 
results  obtained  by  the  hypodermic  injection  of  three 
drops  of  the  tincture  of  aconite  root  every  half  hour, 
until  the  reduced  pulse  and  free  sweating  indicated 
the  system  was  coming  under  the  influence  of  the 
cardiac  sedative. 

Of  course,  I  do  not  mean  to  encourage  the  im- 
proper or  too  free  use  of  the  lancet  in  these  cases,  but 
in  the  few  instances  of  death  during  acute  exacerba- 
tion of  cerebral  syphilis  that  I  have  seen,  I  have  almost 
invariably  regretted  that  blood  had  not  been  taken  at 
at  once,  and  very  freely  at  the  beginning  of  the 
acute  attack.  After  venesection,  or  in  feeble  cases 
as  a  substitute  for  it,  the  usual  measures  of  relief 
in  cerebral  congestion  should  be  instituted — cup- 
ping to  the  back  of  the  neck,  stimulating  clysters  of 
turpentine  or  assafetida,  sinapisms  to  the  legs  and 
arms,  cold  to  the  head,  croton  oil  as  a  derivative  by 


—  93  — 
the  mouth.  These  and  other  well-known  remedies  or 
remedial  measures  scracely  require  discussion,  as  their 
use  is  directed  against  the  brain  congestion  and  not 
against  its  cause,  and  therefore  independent  of  the 
nature  of  such  cause. 

In  chronic  cerebral  syphilis,  dry  cupping  and 
the  actual  cautery  may  occasionally  be  employed 
with  temporary  advantage,  but  they  are  rarely  of  much 
value.  When  there  is  cachexia  or  marked  failure  of 
the  general  health,  the  careful  use  of  fresh  air,  tonics, 
rest,  regulated  exercise,  diet,  and  the  other  hygienic 
measures  for  building  up  of  the  health,  are  some- 
times of  service.  So  long,  however,  as  the  cause  of 
the  failure  of  health  remains,  so  long  will  these 
measures  be  of  little  value;  and  when  by  antisyph- 
ilitic  treatment,  the  cause  has  been  removed,  the 
bodily  condition  will  usually  right  itself.  For  this 
reason  in  cerebral  syphilis,  all  measures  other  than 
those  distinctly  antispecific,  are  comparatively  of  very 
little  importance. 

In  an  individual  case  of  cerebral  syphilis,  the  first 
therapeutic  question  which  must  be  decided  by  the 
practitioner,  is  as  to  whether  mercurials  or  the  iodides 
shall  be  employed.  As  a  medical  student,  I  was 
taught  that  the  iodide  of  potassium  is  suitable  for 
the  treatment  of  advanced  syphilis,  while  the  mer- 
curials should  be  chiefly  reserved  to  combat  the  early 
manifestation  of  the  disorder.  There  is  a  certain 
amount  of  truth  in  this  distinction,   but  what  truth 


—  94  — 

there  is  applies  not  so  much  to  cases  of  cerebral 
syphilis  as  to  other  forms  of  the  advanced  disease. 
Cerebral  gummata  may,  of  course,  develop  when  dis- 
ease of  the  bone  and  deep  tissues,  shows  a  wide- 
spread general  infection,  which  is  also  manifested  by 
the  failure  of  vitality;  but  in  the  great  majority  of 
cases  of  cerebral  syphilis  that  have  come  under  my 
care,  especially  in  private  practice,  there  have  been  no 
pronounced  wide-spread  lesions,  no  general  breaking 
down  of  tissue,  and  no  cachexia. 

To  my  thinking,  the  decision,  whether  iodides  or 
mercurials  should  be  employed,  ought  to  rest  upon 
the  symptoms  of  the  individual  case  rather  than  upon 
the  stage  of  the  disorder.  The  contraindication  for 
the  free  use  of  mercurials  is,  not  the  number  of  years 
since  the  primary  affection,  but  a  condition  of  low 
vitality  and  a  tendency  to  necrotic  changes.  Under 
these  circumstances,  mercurials,  if  employed  at  all, 
must  be  used  with  the  greatest  caution.  In  a  few  such 
cases,  however,  I  have  obtained  the  best  results  by 
withdrawing  the  ordinary  mercurials  and  iodides,  and 
giving  large  doses  of  tincture  01  iron  with  small  doses 
of  corrosive  sublimate,  although  there  was  a  distinct 
cachexia.  The  following  prescription  affords  a  mix- 
ture the  taste  of  which  is  not  usually  objected  to.  The 
dose,  and,  indeed,  the  proportion  of  the  ingredients, 
should  be  varied  to  suit  individual  cases. 


—  95  — 
Pf.      Hydrarg.  chl.  corrosiv.,  gr.  iss. 

Tr.  ferri  chloridi,  f  3  ii- 

Glycerinse,  f  ?  i. 

Ol.  caryophylli,  TTtxviii. 

Syrupi,  q.  s.  ad  f  3  xviii. 
M.     S.— Teaspoonful  after  meals,  in  water. 

A  very  great  disadvantage  attends  the  use  of  the 
iodides,  namely,  the  slowness  of  their  action.     In  some 
cases  this  is  a  matter  of  minor  importance,  but  in  other 
instances  it  is  vital.     There  occur  to  my  remembrance 
at  this  moment,  two  cases  in  which  the  iodides   were 
being  used  freely,  and   in  which  the  symptoms  had 
greatly  ameliorated,  although  occasional  epileptic  con- 
vulsions still  occurred.     In  each  case  the  respiratory 
arrest  of  an  epileptic  fit  lasted  a  moment  too  long,  and 
death  resulted.     At  the  autopsies  gummatous  lesions 
were  found,  which  were  evidently  yielding  to  the  iodide 
of  potassium.     The   iodide  would   probably  have  suf- 
ficed for  the  cure  had  it  not  been  for  the  fatal  accidents 
of  the  long  arrest  of  respiration;  but  if  mercury  had 
been  exhibited  so  soon  as  the  cases  came  under  care, 
the  rapid  removal  of  the  lesions  would  have  probably 
prevented  the  fatal  fit.       More  and  more  has  it  be- 
come with   me  a  favorite   rule   of  action   in  cerebral 
syphilis,  without   evidences  of  cachexia  or  a  distinct 
history  of    mercurialization,   to   begin    the    treatment 
with  mercury  in  such  doses  as  are  necessary  to  cause 
very  slight  salivation,  and  to  maintain  a  mercurial  im- 
pression just  below  the  line  of  slight  tenderness  of  the 
gums,  for  some  days  or  weeks,  pro  re  nata. 


-  96  — 

So  far  as  the  specific  lesion  is  concerned,  it  makes 
little  or  no  difference  how  the  mercury  is  introduced 
into  the  system;  and  the  method  of  administration 
should  be  suited  to  the  exigencies  of  the  individual 
case.  When  there  is  no  disturbance  of  the  alimentary 
canal,  and  when  the  mercurials  are  borne  without  inter- 
fering with  the  taking  or  assimilation  of  food,  I  believe 
the  administration  of  the  remedy  by  the  mouth  is  the 
more  accurate  plan,  both  as  to  dosage  and  effect.  When 
the  symptoms  are  extremely  urgent,  and  it  is  desired 
to  affect  the  system  as  rapidly  as  possible,  mercurial 
inunctions  should  be  practiced  whilst  the  drug  is  be- 
ing given  by  the  mouth;  and  when  there  is  a  tendency 
to  diarrhoea,  the  mercurial  inunction  should  be  used 
alone.  By  some  practitioners  the  officinal  oleate  of 
mercury  is  preferred  to  the  ointment,  on  the  ground 
of  its  being  more  cleanly  and  more  rapidly  absorbed; 
but  after  considerable  trial,  I  have  been  unable  to  obtain 
evidences  that  the  oleate  yields  itself  more  rapidly  to 
absorption  than  does  the  older  preparation,  and  it  has 
seemed  to  me  distinctly  more  irritant.  A  half  drachm 
of  the  ointment  or  the  oleate  may  be  rubbed  into  the 
skin  at  a  time,  in  a  warm  room,  and  let  remain  on 
the  person.  An  excellent  plan  is  to  order  the  patient, 
commencing  with  the  beginning  of  the  week,  to  rub 
the  ointment,  on  Sunday  night,  into  the  left  axilla; 
Monday  night,  into  the  left  flank  or  side  of  the  abdo- 
men; Tuesday  night,  into  the  inside  of  the  left  thigh; 
Wednesday   night,   into   the   right   axilla;    Thursday 


—  97  — 
night,  into  the  right  flank;  Friday  night,  into  the 
right  thigh;  Saturday  night,  into  the  region  of  the 
umbilicus;  after  this,  recommencing  with  the  left 
axilla.  A  method  which  has  been  much  practiced  in 
Europe  is,  that  of  giving  mercury  hypodermically; 
but  I  believe  that  the  dangers  of  local  inflammation 
are  such  as  to  over  balance  any  superiority  of  the  plan. 
Smirnoff's  modification  of  the  Scarenzio  method  is  prob- 
ably the  best  of  the  various  attempts  to  overcome  the  lo- 
cal evils  of  mercurial  hypodermic  medication.  A  mixture 
of  calomel  and  chloride  of  sodium,  ten  per  cent,  each, 
in  distilled  water,  is  used  in  such  dose  that  one  and 
one-half  grains  of  calomel  are  injected  deep  into  the 
buttocks  in  the  neighborhood  of  the  vertical  fold, 
which  in  most  lean  persons  is  about  an  inch  and  a  half 
back  of  the  trochanter.  Two  injections  should  be 
administered  at  one  time  on  opposite  sides  of 
the  body;  and  should  never  be  given  less  than  four 
days  apart,  and  when  the  symptoms  are  not  urgent, 
only  once  a  week. 

In  practicing  this  injection,  absolute  antiseptic 
precautions  should  be  taken.  My  first  experience  with 
this  method  was  so  unfortunate  as  to  discourage  its 
use  entirely.  One  double  injection  was  practiced 
upon  a  patient  suffering  from  cerebro-spinal  syphilis, 
in  the  University  Hospital.  About  ten  days  after  the 
injection  had  been  given,  the  patient  left  the  hospital 
without  notable  local  symptoms,  but  ten  days  or  two 

weeks  later,    came  back  with  very     deep    sloughing 
e  gg 


-98- 

ulcerations  at  the  seat  of  the  injections.  In  spite  of 
all  that  could  be  done,  these  sloughs  increased  in  size, 
and  the  patient  died  seemingly  in  a  considerable  de- 
gree from  the  exhaustion  produced  by  the  local  dis- 
ease. 

After  a  mercurial  course,  either  in  the  syphilitic  or 
nonsyphilitic  subject,  iodide  of  potassium  should  be 
given  in  order  to  secure  elimination  of  the  mercury 
from  the  system.  When,  in  a  case  of  cerebral  syphilis, 
the  time  for  the  exhibition  of  the  iodide  has  arrived^ 
the  question  of  the  dose  becomes  important.  It  is 
usually  best  to  begin  with  10  grains  three  times  a  day; 
in  the  course  of  two  or  three  days  this  may  be  in- 
creased to  20  grains.  Usually  the  patient  who  will 
tolerate  a  drachm  of  iodide  a  day  will  also  tolerate 
two  drachms  a  day.  A  majority  of  those  persons 
who  can  take  two  drachms  a  day  without  the 
production  of  iodism  .  can  take  three  drachms.  It 
is,  therefore,  safe  to  advance  the  dose  very  rapidly 
after  it  has  been  found  that  a  drachm  a  day  causes  no 
inconvenience.  Not  rarely  it  seems  almost  impossible 
to  produce  iodism.  I  have  frequently  given  the 
iodides  up  to  or  even  beyond  six  drachms  a  day.  I 
do  not  believe  that  larger  amounts  than  these  are  of 
any  especial  service,  and  I  am  not  sure  that  any  ad- 
vantage is  gained  by  going  beyond  a  daily  dose  of 
half  an  ounce.  Although  the  iodide  is  known  to  pass 
readily  through  animal  membranes,  the  suggestion 
naturally  presents  itself  that  probably  much  of  such  a 


—  99  — 
dose  as  this  fails  of  absorption.  In  order  to  test  this 
question,  I  recently  had  a  quantitative  analysis  made 
by  Dr.  John  Marshall,  Demonstrator  of  Chemistry  in 
the  Medical  Department  of  the  University  of  Pennsyl- 
vania, of  the  urine  of  a  patient  who  was  taking  three 
hundred  and  sixty  grains  of  the  iodide  a  day.  The 
results  were  as  follows: 

First  twenty-four  hours, — total  quantity  of  urine 
passed  1253  c.c. ;  potassium  iodide,  16.84  grammes 
(258  grains). 

Second  twenty-four  hours, — total  quantity  of  urine 
passed  162 1  c.c;  potassium  iodide,  20.2  grammes  (310 
grains). 

Third  twenty-four  hours, — total  quantity  of  urine 
passed  1531  c.c;  potassium  iodide,  17.606  grammes 
(270  grains). 

Fourth  twenty-four  hours, — total  quantity  of  urine 
passed  1078  c.c;  potassium  iodide,  14.488  grammes 
(222  grains). 

The  average  daily  amount  of  the  iodide  recovered 
from  the  urine  by  Dr.  Marshall  was  two  hundred  and 
sixty-five  grains  against  three  hundred  and  sixty 
grains  ingested.  It  is  almost  certain  that  the  iodide 
when  given  in  large  amounts  is  freely  eliminated  by 
the  intestines,  as  well  as  in  the  saliva  and  perspiration, 
and  I  think  the  reader,  making  a  proper  allowance  for 
such  loss,  will  agree  with  me  that  the  work  of  Dr. 
Marshall  shows  that  the  iodide,  when  given  in  daily 
doses  of  three  hundred  and  sixty  grains,  is  practically 
all  absorbed. 


Whenever  symptoms  of  iodism  are  apparent  in 
eases  of  cerebral  syphilis,  the  remedy  should  be  with- 
drawn for  a  few  days,  and  then  smaller  doses  admin- 
istered, the  effort  being  to  keep  just  within  the  line  of 
iodic  intoxication.  Owing  to  the  necessity  for  fre- 
quent varying  of  the  dose,  it  is  preferable  to  exhibit 
the  iodide  in  solution  by  itself,  adding  the  vehicle 
used  to  cover  the  taste  of  the  iodide  at  the  time  of 
administration. 

The  iodide  is  so  soluble  that  a  watery  solution, 
one  minim  of  which  represents  a  grain  of  the  salt,  is 
readily  made,  and  is  permanent.  I  have  been  accus- 
tomed to  use  the  following  formula,  directing  the  pa- 
tient to  add  to  a  dessert  or  tablespoonful  of  Na  2  and 
a  quarter  tumbler  of  water,  the  desired  number  of 
minims  of  No.  1 : 

3     Potassii  iodidi,   §  i. 
Aquae,  q.  s.  ad  f  %  ii. 
S.— No.  1. 

3     Syr.  sarsaparillae  comp.,  f  §  viii. 
S.— No.  2. 

At  one  time  the  profession  had  a  great  deal  of 
confidence  in  the  value  of  the  so-called  "  Woods  "  in 
advanced  syphilis;  at  present  they  are  very  little  used, 
yet  I  am  not  sure  that  they  possess  no  value.  At 
present  writing  one  case  recurs  to  my  mind  in  which 
a  long  treatment  with  the  ordinary  forms  of  mercurials 
and  iodides  had  entirely  failed  to  achieve  good;  but 


IOI     

in  which  "  Zittman's  Decoction  "   was  exhibited   with 
rapid  results. 

The  compound  syrup  of  sarsaparilla  is  too  feeble 
in  medicinal  ingredients  to  be  of  value  except  as  a 
vehicle  to  cover  the  taste  of  the  iodide.  Moreover, 
the  large  amount  of  sugar  which  it  contains  unfits  it 
for  use  in  massive  doses.  If,  however,  the  compound 
fluid  extract  of  sarsaparilla  be  added  to  it,  the  patient 
will  get  a  very  fair  imitation  of  the  older  preparation 
of  the  "Woods."  The  following  preparation  may 
therefore  be  substituted  for  No.  2  of  the  formula  just 
given: 

5      Syr.  sarsaparilla  comp., 

Ext.  sarsaparilla  fid.  comp.,  aa  f  ?  iv. 

S.     No.  2.     Dose,  a  dessert  spoonful. 


CHAPTER  III. 

SPINAL  SYPHILIS. 
Section  I.     Pathology. 

Our  knowledge  of  spinal  syphilis  is  still  so  imper- 
fect as  to  make  the  discussion  of  the  subject  some- 
what unsatisfactory.  The  recorded  cases,  with  careful 
autopsies  are  few,  and  when  recovery  occurs,  doubt 
must  often  rest  upon  the  location  if  not  upon  the 
nature  of  the  lesion.  Moreover  it  is  especially  difficult 
to  decide  what  cases  shall  be  considered  to  be  instances 
of  true  spinal  syphilis,  since  there  is  scarcely  any  de- 
generation of  the  spinal  cord  which  does  not  frequently 
occur  in  syphilitic  persons,  and  which  has  not  been 
attributed  to  specific  infection.  That  some  relation 
exists  between  syphilis  and  the  contiuous — or  tract — 
scleroses  of  the  cord,  is  generally  acknowledged,  but 
this  relation  is  not  sufficiently  direct  to  force  us  to 
consider  these  Various  chronic  inflammations  as  dis- 
tinctly syphilitic,  and  I  shall  not  in  the  present  broch- 
ure further  consider  the  spinal  scleroses. 

An  acute  myelitis  occasionally  develops  in  the 
syphilitic  subject,  and  it  is  possible  that  the  syphilitic 
taint  may  be  the  direct  cause  of  the  inflammation;  it  has 
also  been  thought  by  some  authorities,  that  the  specific 
disorder  bears  an  etiological  relation  with  subacute 
myelitis,  consequently  I  shall  enter  a  little  more  fully 
into  a  consideration  of  myelitis  and  subacute  myelitis, 


—   io3  — 
although  it  does  not  appear  to  be  proven  that  they  are 
direct  outcomes  of  the  constitutional  disorder. 

In  the  Revue  de  Medecine  (Jan.,  1884)  Dejerine 
records  the  case  of  a  person,  suffering  from  chronic 
syphilis,  in  whom  there  were  fulgurant  pains,  with  in- 
creasing weakness  of  the  legs,  and  subsequently,  after 
very  severe  exposure  to  the  weather,  sudden  devel- 
opment of  complete  paraplegia  followed  by  trophic 
troubles,  and  death  in  twenty-eight  days.  At  the 
autopsy  there  was  found  a  central  myelitis  with  pro- 
nounced lesion  of  the  ganglionic  cells;  inflammatory 
changes  of  the  pia  mater  and  capillaries,  and  neuroglia, 
extreme  alteration  of  the  nerve  roots,  and  secondary  de- 
generation of  the  columns  of  Goll  and  the  lateral  col- 
umns. In  a  second  case  recorded  by  Dejerine,  there 
appears  to  have  been  no  exposure  or  apparent  im- 
mediate exciting  cause.  The  symptoms  and  lesions 
were  similar  to  those  just  spoken  of,  but  death 
resulted  in  eight  days.  Whether  such  attacks  as 
these,  occurring  in  syphilitic  subjects,  are  produced 
directly  by  the  syphilis  or  not,  is  at  present  doubtful. 
The  same  is  true  of  myelitis,  of  which  I  have  reported 
two  rather  peculiar  fatal  cases  in  syphilitic  subjects. 
The  general  symptoms  of  this  affection  are,  progressive 
loss  of  power  with  grossly  exaggerated  reflexes,  severe 
twitchings  and  jerkings  of  the  legs,  rigidity,  usually 
more  or  less  marked  pain  and  other  sensory  disturb- 
ances in  the  legs,  and  finally  partial  anaesthesia  and 
complete  paraplegia,   paralysis  of  bladder,  bed-sores, 


—  104  — 

and  death  from  exhaustion.  At  the  autopsy  the  most 
important  changes  found  in  the  cord  have  been  thick- 
ening of  the  main  blood  vessels,  and  the  presence  of 
great  numbers  of  round  neuroglia-cells  in  both  gray 
and  white  matter,  with  complete  disappearance  of  the 
nerve  tubules.  One  of  my  patients  died  of  a  rapidly 
developed  central  myelitis  supervening  upon  the  sub- 
acute disease,  and  affording  lesions  similar  to  those 
described  by  Dejerine  in  addition  to  the  changes  of 
the  subacute  affection. 

In  another  class  of  spinal  cases  occurring  in 
syphilitics,  the  symptoms  resemble  those  of  the  so- 
called  acute  ascending  paralysis  (Landry's  paralysis). 
According  to  Huebner,  they  are  without  anatomical 
lesions,  but  in  the  majority  of  the  recorded  cases  no 
proper  microscopic  study  of  the  cord  has  been  made. 
Huebner  states,  however,  that  Kussmal  failed  in  one 
case,  after  such  study,  to  detect  lesion.  As  some  of 
these  cases  may  really  have  been  instances  of  peri- 
pheral neuritis,  it  is  essential  that  in  the  future  the 
peripheral  nerves  as  well  as  the  spinal  cord  be  care- 
fully studied.  I  have  seen  one  case  which  might  be 
placed  in  this  category.  The  first  symptom  was 
numbness  in  the  legs,  with  a  small  deep  sharp-cut 
ulcer  on  the  plantar  surface  of  the  great  toe;  directly 
after  this,  loss  of  motion  and  sensation  in  the  legs  and 
thighs,  rapidly  becoming  almost  complete,  and  spread- 
ing quickly  to  the  trunk  and  arms,  so  that  in  one  week 
the    patient    was    a    flaccid,  helpless  mass,  and    the 


—  io5  — 
breathing  so  interfered  with  that  he  was  believed  to 
be  dying.  After  almost  losing  the  power  of  swallowing, 
this  patient  began  to  get  better,  and  finally  so  re- 
gained power  of  his  hands  and  feet  that  he  was  able 
to  partially  dress  himself  and  walk  a  distance  of  ten 
or  twelve  feet,  when  he  was  suddenly  seized  with 
pleuritic  effusion  and  died.  During  the  first  week  of 
the  disease  his  temperature  was  ioo°  F.  At  the 
autopsy  the  spinal  membranes  were  found  to  be  nor- 
mal, but  in  the  cord  there  were  very  distinct  lesions; 
the  neuroglia  seemed  everywhere  more  granular  than 
normal;  the  ganglionic  cells  were  not  distinctly  dis- 
eased; the  white  matter  in  various  places  was  much 
changed,  the  tissue  appearing  abnormally  dense  and 
opaque  where  most  affected;  the  nerve-tubules 
seemed  to  gradually  lose  their  myeline,  and  in  places 
were  reduced  to  simple  axis-cylinders.  Finally,  the 
axis-cylinders  became  smaller  and  smaller  until  in  the 
most  altered  portions  of  the  cord  they  had  disappeared. 
As  the  autopsy  was  obtained  with  great  difficulty,  it 
was  not  possible  to  get  the  peripheral  nerves  for 
study. 

In  regard  to  these  very  acute  cases,  it  seems  to  me 
uncertain  whether  the  disease  should  be  attributed  to 
syphilis.  In  my  case,  twenty  years  had  elapsed 
since  the  chancre,  alcohol  was  habitually  used  in  great 
excess,  and  the  attack  was  apparently  precipitated  by 
great  exposure.  On  the  other  hand,  the  man  bore 
well  enormous  doses  of  iodide  of  potassium,  and 
slowly  progressed  under  them. 


—   106  — 

Huebner  *  gives  as  the  forms  of  syphilis  of  the 
cord: 

First — Syphilitic  neoplasms,  including  those  cases 
in  which  the  neoplasm  is  single,  and  those  in  which  it 
consists  of  small  multiple  and  disseminated  new  form- 
ations on  the  membranes  of  the  spinal  cord. 

Second— Syphilitic  callus,  in  which  there  is  found 
after  death  a  circumscribed  induration  of  the  cellular 
tissue  about  the  cord,  usually  with  adhesion  to  the 
dura  mater. 

Third — Simple  softening  of  the  cord.  This  form 
of  softening  is  described  by  Steenberg.  Heubner 
himself  appears  to  doubt  whether  simple  softening  of 
the  spinal  cord  ever  occurs  as  a  distinct  syphilitic 
lesion,  and  also  further  doubts  the  existence  of  a  gen- 
uine syphilitic  myelitis. 

Fourth — Cases  in  which  the  symptoms  resemble 
those  of  the  so-called  acute  ascending  paralysis,  but  in 
which  after  death  no  lesion  can  be  found. 

Of  these  alleged  forms  of  spinal  syphilis,  the 
fourth  variety  has  already  been  discussed  at  sufficient 
length.  The  third  variety  perhaps  may  be  considered 
to  in  some  degree  correspond  with  that  form  of  disease 
which  will  be  hereafter  known  in  this  paper  as  syphil- 
itic infiltration  of  the  spinal  cord;  but  a  true  softening 
of  the  cord  probably  does  not  exist  as  an  original 
syphilitic  lesion.     Gummatous  tumors  springing  from 


Ziemssen's  Cyclopedia  of   Practical  Medicine,  vol.  xii. 


—   107    — 
the    membranes,  and  gummatous  changes  in  the  cord 
itself,  may  so  far  interfere  with  the   circulation  of  the 
spinal    cord   as   to  produce    softening,   which  would, 
however,  be  not  a  primary,  but  secondary,  lesion,  and 
which,  strictly  speaking,  should  not  be  called  syphilitic. 
The  so-called  syphilitic    callus   as   described  by 
Heubner,  is  probably  not  a  primary  syphilitic  lesion, 
but  rather  the  result  or  remnant  of  a  true  gummatous 
inflammation,  as,  indeed,  Heubner  himself  appears  to 
believe.     The  symptoms  in  a  case  reported  by  Vir- 
chow  were,  stiffness  in   the   nape   of   the   neck,  pains 
in  the  neck  and   arms,  and  finally  paralysis  of  both 
arms.     In  a  case  very  elaborately  detailed  by  Heub- 
ner, the  symptoms  were  pain  in  the   neck  and   right 
arm,  and  later  on  in  the  right  leg  and  left  arm,  fol- 
lowed by  paralysis  of  the  right  arm  without  loss  of 
sensibility,  complete  loss  of  power  of  the  right  arm 
and    leg,  weakness  of  the  left   arm,  and   a   few   days 
later  of  the  left  leg  also.     Some  time  after  this,  the  fol- 
lowing symptoms  progressively  appeared:     Spasms  in 
all  the  extremities,  general  paraesthesise,  incontinence  of 
urine,  difficulty  of  respiration  (first  the  inspiration,  and 
then  the  expiration,  becoming  more  difficult),  paresis 
of  the  tongue,  ptosis  of  the  right  side,  difficulty  of 
swallowing,  and  involuntary  passage  of  faeces.     From 
these  symptoms   the    patient  was   relieved  by  active 
antisyphilitic  treatment;  and  he  finally  recovered  suf- 
ficiently to  follow  his  vocation  as  a  colporteur  for  sev- 
eral years,  although  he  had  a  marked  ataxic  gait.     At 


—  io8  — 

the  autopsy,  covering  much  of  the  cervical  cord,  was 
found  a  large  mass  which  had  evidently  been  formed 
by  consolidation  of  the  membranes.  When  exam- 
ined by  the  microscope  it  was  found  to  consist  of  ordi- 
nary fibrous  connective  tissue,  with  here  and  there 
accumulations  of  pigment  containing  great  numbers 
of  nuclei.  It  is  plain  that  in  this  case  a  widespread 
gummatous  meningitis,  which  by  pressure  was  rapidly 
abolishing  the  functions  of  the  cervical  spinal  cord, 
was  softened  down  by  active  antisyphilitic  treatment, 
but  that  the  local  changes  which  it  had  produced 
could  not  be  removed,  and  the  secondary  so-called 
callus  was  left.  The  syphilitic  callus  of  Heubner 
must  therefore  be  considered,  not  a  variety  of 
syphilitic  disease,  but  the  scar  or  result  of  gummatous 
inflammation  which  has  been  partially  cured.* 

The  most  usual  form  of  gummatous  spinal  syphilis 
is  that  in  which  the  exudate  takes  the  form  of  a  neo- 
plasm or  of  a  series  of  small  independent  neoplasms 
or  growths,  springing  from,  or  at  least  connected  with, 
the  spinal  membranes.  In  some  cases  the  new  growths 
seem  to  arise  from  the  arachnoid  or  pia  mater,  and 
force  their  way  inward;  but  in  others  they  have  a 
tendency  to  grow  outward  and  cause  agglutination  of 


*In  the  latter  portion  of  the  present  chapter  are  recorded 
cases  showing  the  importance,  in  spinal  syphilis,  of  persist- 
ing in  the  use  of  antispecific  remedies  for  years;  and  I  cannot 
help  suspecting  that  in  cases  of  syphilitic  callus  such  practice 
might  sometimes  result  in  ultimate  cure. 


—   io9  — 

all  of  the  cord  membranes,  sometimes  even  disease  of 
the  vertebrae  themselves.  I  have  seen  instances  in 
which  the  neoplasm  invading  the  spinal  cord  had  such 
small  connection  with  the  membranes,  as  to  suggest 
that  the  syphilitic  matter  had  originally  been  deposited 
in  the  cord  itself.  The  neoplasm  is  usually  irregular 
in  shape,  assuming  sometimes  the  form  of  a  sharply- 
defined  tumor,  sometimes  that  of  an  irregular  circum- 
scribed infiltration  of  the  membranes,  and  occasionally 
extending  for  a  considerable  distance  up  and  down 
the  cord. 

The  second  form  of  spinal  syphilis  has  been  es- 
pecially commented  upon  by  Rumpf  (Syphilitische 
Erkrankungen  des  Nervensy stems).  The  change  ap- 
pear to  be  first  a  thickening  of  the  blood  vessels,  and 
especially  a  dilatation  of  their  peri-vascular  spaces, 
with  the  exudation  of  numerous  minute  cells  into  the 
walls  and  around  the  vessels  which  appear  to  be  the 
centres  of  the  infiltration.  The  process  is  usually  ac- 
companied with  adherence  of  the  pia  mater,  which  is 
also  infiltrated  with  cells.  It  would  seem,  therefore, 
that  we  must  at  present  acknowledge  the  existence  of 
two  forms  of  gummatous  or  true  spinal  syphilis— that 
in  which  the  membranes  are  chiefly  the  seat  of  the 
disease,  and  that  in  which  there  is  infiltration  of  the 
cord  from  its  own  vessels.  In  nature  these  two  forms 
usually  co-exist.  It  is  not  very  rare  to  find  a  menin- 
geal growth  which  has  distinctly  invaded  the  cord, 
although  usually  the  growth  remains  distinct  even  if  it 


has  caused  disease  of  the  cord  by  pressure.  On  the 
other  hand,  I  have  never  seen,  at  an  autopsy,  infiltra- 
tion without  disease  of  the  membranes. 

Section  II.     Symptomatology. 

Gummatous  Meningitis.  — It  is  evident  that  the 
symptoms  of  gummatous  spinal  meningitis  must,  more 
or  less,  resemble  those  of  a  subacute  or  chronic  non- 
specific meningitis,  but  at  the  same  time  must  be 
more  or  less  peculiar  and  variable,  because  the  gum- 
matous inflammation  may  be  exceedingly  localized, 
wide  spread,  or  occupy  only  a  small  region.  More- 
over, the  symptoms  must  vary  with  the  seat  of  the 
lesion,  especially  when  the  lesion  is  strictly  localized. 
In  meningitis  the  most  active  manifestations  are  the 
•  results  of  irritation  of  the  nerve  roots.  For  this  reason 
pain  and  spasm  are  prominent,  and  often  precede 
paralysis,  which  is  chiefly  the  outcome  of  pressure. 

The  seat  of  the  pain  usually  corresponds  to  the 
seat  of  the  lesion,  but  is  peripheral  rather  than  centric. 
In  other  words  it  is  referred  to  the  endings  of  the 
nerves  whose  posterior  roots  are  involved  in  the  in- 
flammation. In  some  cases  furious  agonies  shoot  along 
the  arms  or  legs;  and  fulgurant  crises  in  the  extremi- 
ties simulate  those  of  posterior  sclerosis.  Perhaps 
more  frequently  the  pains  are  in  the  trunk,  especially  in 
the  lumbar  or  dorsal  region.  They  are  described  as 
like   the  thrust  of  a  knife,  a  girdle  of  hot  iron,  or  a 


tearing  or  clawing  as  if  by  a  living  animal.  More 
rarely  the  pains  are  comparatively  slight  and  aching  in 
character.  Sometimes  a  fixed  spot  on  the  spinal  column 
burns  or  aches,  or  is  fitly  described  as  an  indescribable 
distress,  and  in  some  cases,  according  to  Heubner,  the 
suffering  is  distinctly  increased  by  pressure  over  the 
spot.  I  have  seen  three  or  four  cases  presenting  the 
last  feature,  but  in  each  instance  have  believed  that  the 
patient  was  suffering  not  simply  from  spinal  syphilis, 
but  also  from  an  implication  of  the  vertebral  perios- 
teum or  of  the  vertebrae  themselves,  and  have  been 
confirmed  in  this  opinion  by  subsequent  events. 
When  the  lesion  is  purely  meningeal  there  is  probably 
no  marked  local  tenderness.  The  following  case  is  of 
great  interest  as  proving  that  syphilitic  deposits  in  the 
spinal  membranes  may  give  rise  to,  or  be  associated 
with,  inflammations,  softening,  and  breaking  down  of 
the  vertebrae. 

B.  C.  Italian.  Entered  the  Philadelphia  Hospital,  June 
i,  1885.  Between  the  man's  natural  stupidity  and  linguis- 
tic difficulties,  it  was  found  impossible  to  get  a  satisfactory 
history;  but  he  stated  that  he  had  been  well  and  strong  until 
three  months  before,  when  he  was  hurt  on  the  neck  and  back, 
and  had  not  been  able  to  work  since.  For  the  last  month  he 
had  noted  that  his  arms  were  steadily  losing  power.  At  the 
time  of  entrance  he  was  evidently  very  ill,  and  was  suffering 
from  general  paralysis .  Lying  in  bed  he  could  make  all  the 
movements  of  the  lower  limbs,  but  with  great  feebleness  and 
slowness;  all  movements  of  the  arm  below  the  elbow  were  lost, 
except  in  the  left  thumb,  and  the  right  fingers  could  be  moved 
only  by  a  very  strong  effort  of  the  will;  power  was  almost  com- 


112    

pletely  lost  in  the  upper  arms,  but  the  deltoids  still  responded 
very  feebly.  The  face  was  not  paralyzed,  and  sensation  was 
well  preserved.  He  complained  of  violent  pain  in  the  back  of 
the  neck  shooting  down  into  the  limbs,  especially  the  arms. 
On  coughing,  there  was  violent  pain  referred  to  the  sternal 
region.  Pressure  over  the  lower  cervical  vertebrae  caused  pain, 
as  did  also  pressure  upon  the  head,  or  attempts  to  move  the 
neck.  There  was  no  control  over  the  urine  and  faeces.  Shortly 
after  entrance  to  the  hospital,  the  patient  developed  a  fatal 
pneumonia. 

At  the  post  mortem  examination,  the  ordinary  lesions  of 
pneumonia  were  foumd.  The  cerebrum,  cerebellum,  and  pons, 
afforded  nothing  abnormal  except  slight  capillary  congestion. 
From  the  third  to  the  sixth  cervical  vertebrae,  there  was  a 
marked  thickening  of  the  membranes  covering  the  cord.  The 
growth  which  gave  rise  to  it  mainly  involved  the  anterior  face 
of  the  cord  and  encircled  about  two-thirds  of  the  circumfer- 
ence. The  bodies  of  the  vertebrae  were  eroded,  and  the  cord 
itself  greatly  thickened  and  broadened.  Below,  the  growth 
terminated  abruptly,  but  above  more  gradually;  and  about  op- 
posite the  fourth  cervical  vertebrae  there  was  a  lenticular  pro- 
tuberance between  the  posterior  and  anterior  roots  on  the  left 
side. 

Microscopic  examination  showed  the  external  mass  to  be 
composed  of  a  structureless  base  containing  numerous  narrow 
curved  cells;  and  the  inner,  portion  of  the  mass  to  be  composed 
of  innumerable  small,  round,  closely  packed  cells,  which  were 
sometimes  irregularly  diffused,  but  were  more  usually  crowded 
into  globular  bodies,  which  were  commonly  melted  into  the 
surrounding  tissue,  but  in  rare  cases  were  more  or  less  dis- 
tinctly isolated.  In  some  of  these  bodies  the  cells  were  under- 
going fatty  degenerations.  At  the  point  of  greatest  pressure, 
the  spinal  cord  was  chiefly  composed  of  structureless  minute 
granular  neurogliar  matter,  with  numerous  roundish  neurogl  iar 


—  H3  — 

connective  tissue  cells,  no  nerve  tubules  being  discovered. 
The  nerve  cells  of  the  gray  matter  could  still  be  made  out, 
but  were  shrunken,  and  mostly  without  processes. 

In  spinal  syphilis  not  only  is  pain  a  characteristic 
symptom,  but  parsesthesise  are  not  rare  phenomena; 
such  are  formications,  tingling  in  the  extremities, 
numbness,  and  feeling  as  though  the  limb  were  asleep, 
intense  sense  of  coldness  on  the  surface,  sensation  of 
water  running  over  the  limb,  etc.  Early  in  the  disorder 
there  is  sometimes  very  marked  hyperesthesia,  but 
later,  even  though  the.  pain  persists,  marked  blunting 
of  sensibility  comes  on,  and  there  may  be  a  complete 
anaesthesia;  this  anaesthesia  is  sometimes  localized  in 
irregular  tracts.  Thus,  in  a  case  reported  by  Alfred 
Mathieu,*  although  there  was  complete  anaesthesia  of 
the  outer  side  of  the  left  leg  and  foot,  the  inner  side 
retained  its  normal  sensibility.  In  some  instances 
there  is  the  abdominal  cincture  of  ordinary  myelitis. 
My  records  show  that  even  in  these  early  stages 
there  may  be  diplopia,  amblyopia,  or  other  disorder 
of  vision,  and  the  pupil  may  be  distinctly  affected. 
In  these  cases  it  is  probably  the  upper  portion  of  the 
cord  which  is  affected. 

Disturbances  of  motility,  in  the  majority  of  cases, 
do  not  develop  until  some  time  after  sensation  has 
been  affected,  but  may  come  on  very  early.  Usually, 
the  first  symptoms  are  those  of  irritation,  such  as 
rigidity  of  the  neck,  back,  and  limbs,  or  even  of  isolated 


*  Ann.  de  Dermatol,  et  Syph.,  vol   iii.,  1882. 

9  GG 


—   ii4  — 

groups  of  muscles.  Tremors  have  been  described  as 
frequently  present.  These  may  be  convulsive,  and 
are  often  plainly  reflex  in  their  origin;  indeed,  I  am 
inclined  to  believe  that  they  are  always  reflex  trem- 
blings, and  never  true  tremors.  Huebner  describes  a 
case  in  which  a  paralyzed  limb  was  thrown  into  violent 
tremblings  whenever  passive  motion  was  attempted. 
The  patella-reflex  is  usually  grossly  exaggerated,  al- 
though it  may  be  lost  in  the  latter  stages  of  the  dis- 
order. Not  rarely  there  is  the  condition  which  has 
received  the  misnomer  of  spinal  epilepsy.  This  exag- 
geration of  the  reflexes  may  be  limited  to  one  leg, 
when  it  is  almost  pathognomonic.  In  some  cases 
severe  cramps  are  excited  by  movement.  Usually 
there  is  no  tenderness  of  the  contracted  muscles. 
These  symptoms  of  the  meningitic  stage  may  con- 
tinue for  weeks  or  even  months,  without  there  being 
pronounced  paralysis,  although  locomotion  is  not 
rarely  interfered  with  by  stiffness  of  the  legs. 
Finally,  if  the  case  progresses,  the  patient  notices  a 
weakness  in  one  or  both  legs,  or  (if  the  disease  be 
situated  high  up  in  the  spinal  cord)  in  one  or  both 
arms,  which  rapidly  increases  until  there  is  almost 
complete  loss  of  power.  This  rapid  increase  of  palsy 
following  long-continued  disturbance  of  sensation,  is 
almost  pathognomonic.  In  most  cases  one  side  of  the 
body  is  more  affected  than  the  other.  The  sphincters 
are  prone  to  be  implicated,  and  in  advanced  stages  of 
the  disease  there  is  usually  complete  loss  of  control 


—  U5  — 
over  the  bladder  and  rectum.  The  patient  may  live 
for  months  without  very  distinct  change  of  this  condi- 
tion, or  bed-sores  and  other  trophic  disturbances  may 
rapidly  develop  and  death  ensue  in  a  short  time.  I 
have  seen  under  these  circumstances  marked  eleva- 
tion of  temperature,  rapid  feeble  pulse,  mental  weak- 
ness, and  the  general  symptoms  of  septicaemia  last  for 
many  weeks.  Ammoniacal  cystitis  is  of  course  prone 
to  be  developed  during  this  stage.  When  motility 
fails,  sensibility  is  usually  blunted,  although  the  pains 
may  even  increase.  Heubner  affirms  that  an  incom- 
pleteness of  the  anaesthesia  is  characteristic  of  the 
disorder. 

Owing  to  the  diseased  condition  of  the  vessels, 
hemorrhages  or  thrombosis  may  suddenly  interrupt 
the  course  of  a  gummatous  disease  of  the  spinal  mem- 
brane. 

In  a  patient  of  my  own  who  was  believed  to  be 
suffering  from  gummatous  spinal  meningitis,  there  was 
an  abrupt  development  of  violent  tearing  pains,  loss 
of  power  and  sensibility,  and  all  the  other  symptoms 
which  are  characteristic  of  meningeal  spinal  hemor- 
rhage. A.  Weber  reports  a  case  in  which,  after  doubt- 
ful premonitory  symptoms,  such  as  vertigo,  loss  of 
power  on  the  right  side,  pressure  on  the  top  of  the 
head,  and  tinnitus  aurum,  there  was  sudden  devel- 
opment of  convulsions,  and  death.  At  the  autopsy,  a 
syphilome  of  the  right  vertebral  artery  was  found, 
with  a  recent  thrombosis  of  the  basilar  artery.* 

*  Amer.  Journ.  of  Neur.  and  Psychiat.,  vol.  ii. 


—  n6  — 

The  typical  course  of  spinal  syphilis,  such  as  has 
been  described,  may  be  variously  departed  from. 
Sometimes  the  power  of  co-ordination  is  early  affect- 
ed, and  the  symptoms  resemble  those  of  locomo- 
tor ataxia.  I  doubt,  however,  whether  under  any 
circumstances  there  is  loss  of  the  knee-jerk  in  the 
early  stages  of  the  gummatous  disease  of  the  spinal 
membrane.  The  lesion  in  such  case  is  probably  an 
infiltration  of  the  cord  itself.  Sometimes  the  paralytic 
symptoms  are  from  the  onset  very  prominent,  because 
the  membranous  disease  has  been  accompanied  by 
rapid  exudation  so  situated  as  to  involve  chiefly  the 
anterior  nerve  roots,  and  by  pressure  and  inflamma- 
tion quickly  suspend  their  functions.  It  may  well 
be,  however,  that  these  cases  of  spinal  syphilis  in 
which  the  symptoms  are  almost  exclusively  paralytic, 
are  due  to  disease  of  the  cord  itself,  although  the 
strictly  localized  character  of  the  symptoms  some- 
times strongly  indicates  that  the  lesion  is  an  external 
tumor.  As  illustrating  this,  I  cite  a  case  reported  by 
Dr.  C.  W.  Suckling  in  the  Birmingham  Medical  Re- 
view, August,  1885,  in  which  a  syphilitic  patient 
distinctly  suffered  from  lack  of  power  attacking  the 
left  leg,  increasing  until  in  the  course  of  a  week  it 
amounted  to  complete  paralysis,  with  hyperesthesia, 
vaso-motor  paralysis,  and  consequent  rise  of  the  local 
temperature  in  the  leg,  accompanied  by  complete  loss 
of  sensation  in  the  opposite  leg.  In  this  case,  there 
was  analgesia  of  the  right  side,  and  hyperesthesia  on 


—  ii7  — 

the  left  extending  to  a  sharply  defined  limit  to  two 
inches  above  the  umbilicus;  but  there  was  no  severe 
pain  at  any  time.  It  is  evident  that  this  patient  suf- 
fered either  from  a  tumor  pressing  on  one  half  of  the 
cord,  or  a  localized  hemimyelitis;"  and  that  the  lesion 
was  specific,  was  strongly  indicated  by  the  almost 
complete  recovery  obtained  by  the  use  of  large  doses 
of  iodide  of  potassium,  and  mercury. 

A  case  illustrating  the  occasional  difficulty  of 
diagnosing  spinal  syphilis  is  reported  by  C.  Eisenlohr.* 
The  first  symptom  was  obstinate  constipation,  with 
very  great  discomfort  after  defecation;  then  appeared 
incontinence  of  urine  with  weakness  of  the  legs; 
finally,  a  sudden  complete  palsy  of  the  right  leg 
with  marked  anaesthesia  in  both  legs,  partial 
loss  of  power  in  left  leg,  violent  boring  abdominal 
pains,  and  distress  in  the  bladder.  In  the  last  stages 
there  were  severe  neuralgic  pains  in  both  legs,  with 
complete  loss  of  sensation,  bed-sores,  atrophy  of  the 
leg  muscles,  with  reactions  of  degeneration,  and  death 
from  exhaustion.  At  the  autopsy  an  advanced  menin- 
gitis was  found  which  had  apparently  commenced  in 
the  region  of  the  cauda  equina,  and  given  rise  to 
complete  degeneration  of  the  nerves.  The  only  alter- 
ation of  the  cord  was  an  ascending  degeneration  of 
the  posterior  columns. 


*  Neurologische,  Centralblatt,  1884,  p.  75. 


—  n8  — 

Diffused  Spinal  Syphilis. 

The  symptoms  of  diffused  syphilitic  infiltration  in 
the  spinal  cord  vary  according  to  the  seat  of  the 
lesion:  paralysis  with  or  without  spasm;  anaesthesia 
with  or  without  pain;  spasm  without  paralysis;  or 
pain  without  anaesthesia,  being  the  most  marked 
manifestations  according  as  the  motor  or  sensory 
tracts  are  chiefly  involved.  When,  as  is  usually  the 
case,  the  march  of  the  organic  alteration  is  slow,  it  is 
evident  that  the  symptoms  will  more  or  less  closely 
resemble  those  of  sclerosis  of  the  affected  part. 
Especially  is  -this  true  since  secondary  degenerations 
of  the  spinal  cord  appear  to  be  very  prone  to  follow 
on  the  primary  lesion. 

Sometimes  paraplegia  chiefly  occupies  the  pa- 
tient's attention;  it  may  be  attended  with  flaccidity  of 
the  implicated  muscles,  but,  perhaps  more  usually,  the 
muscles  are  more  or  less  contracted,  and  the  reflexes 
excited  so  that  a  clinical  picture  resembling  that  of 
spastic  palsy  is  formed.  In  such  cases  severe  pain  is 
rare,  but  paraesthesia,  coldness  af  the  extremities,  and 
some  loss  of  sensibility  are  not  infrequently  present; 
when  a  syphilitic  spastic  paraplegia  is  accompanied 
by  severe  pain,  the  probabilities  are  very  strong  that 
the  lesion  is  in  the  membrane  of  the  cord. 

In  other  patients  the  function  of  co-ordination  is 
especially  at  fault,  and  the  action  and  gait  may  re- 
semble those  of  a  true  locomotor  ataxia.  This  re- 
semblance may  be  further  intensified  by  the  existence 


—    ny  — 
of  lancinating  and  fulgurant  pains  in  all  respects  pre- 
cisely like  those  of  a  true  posterior  sclerosis. 

Sexual  excitation  preceding  or  during  an  attack 
of  spinal  syphilis  is  rare,  but  may  occur.  Pain  is  not 
nearly  so  frequent  and  prominent  a  phenomena  as  in 
specific  spinal  meningitis,  arid  when  present  usually 
resembles  that  of  a  posterior  sclerosis.  Girdle  sensa- 
tions are  not  rare. 

It  is  hardly  necessary  to  occupy  space  with  a 
further  detailed  description  of  the  various  symptoms 
which  are  present  in  syphilis  attacking  the  spinal  cord 
itself.  They  are  precisely  the  same  symptoms  as  are 
produced  by  other  organic  diseases  of  the  cord.  The 
characteristic  features  of  the  disease  are  not  so  much 
in  the  individual  symptoms  as  in  their  collocation. 
The  lesions  of  syphilis  are  prone  to  be  multiple,  and 
are  rarely  as  strictly  confined  to  individual  functional 
tracts  as  is  sclerosis;  consequently  the  symptoms  of 
syphilis  of  the  cord  are  very  apt  to  be  mixed.  Thus 
there  will  be  loss  of  co-ordination  associated  with  re- 
tention of  the  patella-reflex, — or  the  patella-reflex 
may  be  lost  at  a  time  when  there  is  marked  loss  of 
power  in  the  muscles  rather  than  loss  of  their  co- 
ordinating function;  or  an  apparently  true  picture  of 
locomotor  ataxia  may  be  afforded  save  only  that  there 
are  distinct  girdle  pains  like  those  of  myelitis;  or  an 
apparent  locomotor  ataxia  will  be  associated  with  loss 
of  power  over  the  rectum,  or  bladder;  or  a  case  which 
up  to  a  certain  point  offers  a  typical  outline  of  lateral 


120    

sclerosis,  suffers  from  fulgurant  pains,  or  from  par- 
alysis of  the  sphincters. 

Almost  any  conceivable  mixture,  or  interweaving 
of  spinal  symptoms,  may  occur  as  the  result  of  syphilis 
of  the  cord,  so  that  the  most  pathognomonic  evidence 
of  the  existence  of  the  disease  is  an  atypical  aggrega- 
tion of  symptoms.  Whenever  a  contradictory  mass  of 
phenomena,  evidently  spinal  in  origin,  present  them- 
selves before  the  practitioner,  the  suspicion  should  at 
once  be  strongly  aroused  that  the  patient  is  suffering 
from  the  specific  disorder. 

Instead  of  discussing  further  the  symptoms  of 
syphilis  of  the  spinal  cord,  I  shall  give  short  descrip- 
tions of  several  cases  which  have  been  under  my  care, 
in  which  the  diagnosis  has  been  confirmed  by  the  re- 
sult of  antispecific  treatment.  It  is  possible  that  in 
some  of  these  cases  both  cord  and  membranes  were 
affected;  and  it  seems  to  me  very  certain,  that  often  it 
is  impossible  to  say  during  life,  how  far  the  lesion  is 
meningeal  or  spinal. 

Mr.  J.  J.  presented  himself  to  me  for  treatment  the  early 
part  of  the  past  winter,  and  has  therefore  been  under  care 
for  about  six  months.  My  notes  taken  at  the  time  of  the 
first  visit  are  as  follows: 

"  Suffers  much  with  violent,  shooting,  darting,  boring 
pains  in  the  legs,  resembling,  according  to  his  description,  those 
of  locomotor  ataxia.  At  the  time  of  the  pain,  slight  contact 
with  the  part  increases  the  suffering;  but  seizing  the  part 
firmly,  or  rubbing  it  hard,  brings  some  relief.  The  knee  jerk 
is  abolished,  but  is  produced  to  a  slight  extent  when  the  blow 


a 


is  reinforced  by  his  violently  clenched  hands.  There  are 
no  cerebral  symptoms;  the  pupils  are  small,  not  affected  by 
light  or  pinching,  but  dilated  slightly  when  he  looks  at  far-off 
objects,  showing,  therefore,  Argyll- Robertson  pupil.  Both 
the  station  and  walk  are  exceedingly  imperfect  and  unsteady, 
and  there  is  great  loss  of  endurance,  so  that  walking  a 
very  short  distance  exhausts  him  entirely."  Mr.  J.  was  put 
upon  iodide  of  potassium  and  corrosive  sublimate  in  full 
doses,  and  commenced  to  improve.  At  present,  he  considers 
himself  well,  as  he  is  able  to  walk  long  distances  without  un- 
due fatigue,  and  in  the  last  two  months  has  only  suffered  once  or 
twice  from  pains  just  before  a  severe  storm.  His  station  and 
gait  are  each  of  them  normal,  or  nearly  so,  but  the  pupils  have 
only  very  imperfectly  regained  the  power  of  responding  to 
light,  and  the  knee  jerk  is  still  absent. 

Wm.  M.  stated  that  he  had  chancres  15  years  before;  also 
history  of  great  sexual  excess.  In  December,  1885,  first 
noticed  that  his  gait  was  unsteady;  at  the  same  time  suffered 
from  sickening  pains  in  the  lumbar  region,  and  loss  of  sexual 
desire.  In  March  or  April  he  began  to  have  lightning  pains 
in  the  legs  like  those  of  locomotor  ataxia.  The  loss  of  control 
over  his  legs  became  more  and  more  manifest,  and  by  the  5  th 
of  July  he  was  unable  to  walk;  according  to  his  statement,  this 
inability  was  due  to  lack  of  control  rather  than  to  lack  of  power. 
There  was  also  a  time  when  he  could  not  walk  at  night,  although 
he  could  in  the  day  time.  About  this  time  "girdle  sensations  " 
were  felt  at  night,  and  he  suffered  much  from  coldness  and 
numbness  of  the  feet.  He  states  that  at  one  time  he  had 
diplopia;  there  had  been  no  headache,  and  no  loss  of  memory; 
but  he  had  irritability  of  the  bladder  during  the  day,  incontin- 
ence during  the  night,  When  he  entered  the  University  Hos- 
pital, September  20th,  his  general  appearance  was  that  of  a 
healthy  man,  and  he  presented  no  other  symptoms  except 
those  connected  with  his  legs  and  bladder;  the  knee  jerk  was 


122    

absent  on  both  sides;  there  was  a  great  loss  of  power  in  aD 
the  muscles  of  the  legs,  and  although  there  was  no  wasting  of 
the  muscles,  the  electrical  response  was  more  sluggish  than 
normal.  Sensation  was  very  distinctly  blunted  in  both  legs, 
and  also  appreciably  delayed.  The  aesthesiometer  points  were, 
in  most  portions  of  the  leg  surface,  not  separated  at  less  than 
ii  inchees,  and  nowhere  nearer  than  7  inches.  The  ocular 
examination  showed  disk  atropic,  greenish;  retinal  vessels 
small;  right  eye  vision  -i£;  left  eye  vision  _1L. 

Argyll- Robertson  pupil  was  present;  no  ocular  paralysis 
was  discoverable.  The  urine  was  normal.  Patient  was  treated 
with  mercurials  by  the  mouth,  and  by  inunctions,  and  by  iodide 
of  potassium.  Great  improvement  took  place,  but  he  left  the 
hospital  before  he  was  cured. 

Wm.  Dougherty.  Admitted  to  the  University  Hospital, 
Feb.  29,  1888.  During  the  three  months  before  admission 
suffered  from  steady  pain  in  the  back,  which  during  the 
last  month  had  been  accompanied  by  girdle  pains  and  marked 
tendency  to  excessive  sleepiness  and  alteration  of  the  gait; 
further  states  that  he  has  been  affected  with  headache  and 
slowness  of  speech  for  the  last  year.  At  present  is  unable  to 
rise  from  the  chair  except  with  aid  of  his  arms,  on  account  of 
stiffness  and  feebleness  of  his  legs;  walks  with  the  true  spastic 
gait,  but  watches  the  ground  carefully;  on  closing  his  eyes  his 
gait  becomes  staggering,  but  is  still  able  to  walk.  Sensibility 
greatly  impaired  on  the  abdomen,  buttocks,  and  legs.  He  was 
put  on  the  use  of  one  drachm  of  the  iodide  of  potassium  a  day, 
and  improved  very  rapidly  in  his  gait  and  also  in  his  speech- 
After  being  in  the  hospital  a  little  under  two  months  he  was 
discharged,  with  the  note  that  he  could  walk  very  well. 

The  following  cases  which  occurred  in  my  service 
at  the  University  Hospital,  have  been  reported  a  little 
more  in  detail  by  the  chief  of  clinic,  Dr.  F.  X.  Dercum,. 


—   i23  — 
in  the  University  Medical   Magazine,   for  November, 
1888: 

J.  W.,  aged  34,  at  his  first  visit  to  the  clinic  was  so  ex- 
tremely ataxic  that  he  was  unable  to  walk  unless  assisted 
on  each  side  by  a  friend;  swaying  when  standing  was  extreme; 
there  were  ataxic  pains  in  the  calves,  feet,  and  thighs;  the  knee 
jerk  was  absent;  and  the  sesibility  in  both  hands  and  feet  was 
much  diminished.  The  symptoms  much  resembled  those  of 
locomotor  ataxia,  but  were  aberrant  in  that  there  were  painful 
spasms  of  the  muscles  of  the  legs.  Under  the  use  of  the 
iodides  and  mercurials  slight  improvement  was  obtained;  but 
it  was  not  until  the  third  year  of  his  attendance  at  the  dispen- 
sary, and  after  the  prolonged  administration  of  moderate 
doses  of  antisyphilitic  remedies,  that  a  very  distinct  gain  was 
achieved.  He  then  steadily  became  less  ataxic  until  he  was 
able  to  walk  by  himself  well,  although  the  diminished  sen- 
sibility persisted,  as  did  also  the  loss  of  the  knee  jerk. 

H.  A.,  aged  32,  decidedly  ataxic  in  both  arms  and  legs, 
shooting  pains  in  the  calves  of  the  legs,  loss  of  sensibility 
in  the  feet,  and  some  paresthesia.  The  knee  jerk  was  absent 
except  upon  reinforcement  by  muscular  effort  in  distant  parts 
of  the  body.  The  general  health  .was  much  impaired.  In  this 
case  the  aberrant  symptoms  were;  constriction  of  the  abdomen, 
and  great  tenderness  upon  pressure  over  certain  widely  separ- 
ated nerve  trunks.  Specific  treatment  was  kept  up  steadily  for 
thirteen  months,  when  the  pains  began  to  diminish;  the  knee 
jerk,  although  still  absent  when  the  man  was  quiet,  became 
more  active  upon  reinforcement,  and  the  ataxia  began  to  grow 
less.  By  the  end  of  three  years  the  improvement  was  very 
striking,  and  when  the  patient  walked  with  the  eyes  open,  the 
gait  was  almost  normal. 


—  124  — 

Section  III.     Prognosis. 

Owing  probably  to  the  minute  size  of  the  cord, 
and  the  great  consequent  tendency  to  suffer  irrepar- 
ably from  pressure  or  from  spreading  inflammation, 
the  prognosis  in  spinal  syphilis  should  be  even  more 
guarded  than  in  syphilis  of  the  brain,  at  least  so  far 
as  concerns  absolute  cure.  In  a  large  majority  of 
cases,  however,  very  great  improvement  of  the  patient 
can  be  obtained  by  treatment,  and  brilliant  cures  are 
not  very  rare;  but  even  in  these  so-called  cures,  how- 
ever, careful  examination  will  often  reveal  the  exist- 
ence of  permanent  damage. 

Section  IV.     Treatment. 

The  most  important  part  of  the  treatment  of 
spinal  syphilis  consists  in  the  use  of  the  iodides  and 
the  mercurials.  The  remarks  which  have  already  been 
made  in  regard  to  the  proper  employment  of  these 
drugs  in  brain  syphilis,  apply  with  equal  force  to 
specific  disease  of  the  cord  or  its  membranes.  It 
should  always  be  remembered  that  it  is  essential  in 
diseases  of  the  cord  to  remove  the  gummatous  lesion 
as  rapidly  as  possible,  lest  by  pressure,  or  by  exciting 
inflammation,  it  produce  irreparable  damage.  Con- 
sequently, unless  distinct  contra-indications  exist,  mer- 
cury should  always  be  employed  at  once,  and  freely, 
the  amount  exhibited  being  suited  t©  the  exigen- 
cies of   the  individual    case.      In    very    many  cases 


—  i25  — 
during  the  antispecific  medication,  either  absolute  or 
partial  rest  should  be  enforced,  to  prevent  spinal 
irritation  or  exhaustion.  The  proper  use  of  the  alter- 
nate hot  and  cold  douche,  massage,  muscle  beaters, 
and  other  remedial  measures  employed  in  spinal  dis- 
ease, is  often  advantageous,  but  of  very  slight  import- 
ance compared  with  the  specific  medication. 

In  the  present  brochure,  it  does  not  seem  neces- 
sary to  discuss  m  elaborate  detail  the  application  of 
these  subordinate  remedial  measures.  They  are  ap- 
plied to  meet  precisely  the  indications  for  which  they 
are  used  in  other  spinal  diseases.  Concerning  one  or  two 
of  them,  however,  the  reader  may  pardon  a  few  words. 
The  alternate  cold  and  hot  douche,  properly  applied, 
is  sometimes  of  the  greatest  service  when  the  limbs 
are  cold,  the  muscles  slowly  wasting,  or  very  sluggish 
in  their  action,  and  the  peripheral  circulation  impaired. 
Under  these  circumstances,  the  patient  should  sit  with 
the  feet  in  a  shallow  tub  of  hot  water,  and  then  water 
as  hot  as  can  be  borne  should  be  poured  down  and 
over  the  legs  for  three  or  four  minutes,  and  be  im- 
mediately followed  by  a  douche  of  water  of  the  tem- 
perature of  400  F.  for  one  minute;  or,  what  is  more 
effective,  the  legs  should  be  rapidly  rubbed  with  a 
large  piece  of  ice  for  from  one  to  two  minutes.  The 
hot  douche  may  then  be  reapplied,  and  the  ice  rub- 
bing again  enforced.  The  effect  of  this  treatment 
upon  the  circulation  of  the  leg  is  usually  immediate 
and  pronounced. 


126    

A  more  important  matter  than  the  douche  is  the 
use  of  suspension  in  those  cases  in  which,  along  with 
the  tumor  of  the  membranes,  there  is  local  tenderness 
due  to  an  implication  of  the  vertebrae.  For  many 
years  it  has  been  recognized  that  the  great  indication 
in  the  treatment  of  syphilitic  or  other  forms  of  Pott's 
disease  is,  extension  and  removal  of  the  superimposed 
weight  from  the  diseased  vertebra.  Various  devices 
for  meeting  this  indication  of  extension  have  been 
from  time  to  time  suggested,  and  the  value  of  the 
plaster  jacket  as  a  means  of  making  permanent  the 
temporary  extension  gained  by  hanging  up  a  patient, 
is  universally  recognized.  The  effectiveness  of  this 
jacket  depends  upon  the  fact  that  the  general  shape 
of  the  human  body  is  that  of  two  opposed  cones,  which 
are  placed  in  such  a  position  that  the  base  of  one  is 
the  shoulders,  and  that  of  the  other  the  pelvis. 

It  occurred  to  me  that  it  might  be  possible  to  use 
the  upper  cone  of  the  body  as  the  basis  for  suspension; 
for  this  purpose  the  plaster  jacket  being  made  with 
loops  over  the  shoulder  and  the  patient  hung  by 
means  of  the  tripod,  the  J.  K.  Mitchell  chair,  a  properly 
constructed  wheel  crutch,  or  other  device  suited  to 
the  individual  needs.  I  have  found  that  an  upward 
pull  upon  the  jacket  of  80  pounds  does  not  disturb  its 
position,  even  when  maintained  for  several  hours,  and 
that  the  pressure  is  uniformly  spread  over  the  surface, 
so  that  no  pain  or  discomfort  is  caused.  In  order  to 
make  the  extension  as  complete  as  possible,   it  has 


—  127  — 

been  found  advisable  to  add  to  the  jacket  an  ordinary 
head-strap,  so  that  when  the  patient  is  supported  there 
is  some  pull  upon  the  head  as  well  as  upon  the  jacket, 
care  being  exercised  not  to  draw  up  the  head  suffi- 
ciently to  cause  discomfort. 

I  have  tried  several  methods  for  making  the  loops 
in  the  spinal  jacket,  but  the  one  which  I  first  sug- 
gested has  proved  most  satisfactory.     It  is  as  follows: 

After  the  first  layer  of  the  jacket  is  upon  the  pa- 
tient, a  piece  of  webbing,  linen  bandage,  or  other 
strong  material,  well  wetted,  has  one  end  applied  to  the 
edge  of  the  jacket,  in  front  and  on  one  side.  The 
webbing  or  bandage  is  then  carried  up  over  the 
shoulders,  upon  which  it  rests  very  loosely,  and 
brought  back  of  the  jacket  to  the  lower  edge  behind. 
A  similar  bandage  is  then  put  upon  the  opposite  side 
of  the  jacket;  then  the  external  layers  of  the  jacket  are 
put  in  place.  In  this  way  the  strips  which  are  used 
for  the  shoulder-loops  are  so  incorporated  with  the 
jacket  that  they  cannot  be  pulled  out;  at  the  same 
time  there  is  no  tendency  for  the  jacket  to  be  broken 
or  crumpled  up  when  the  extension  is  applied. 

The  ordinary  method  of  using  the  plaster  jacket 
simply  secures,  more  or  less  completely,  a  permanence 
of  the  extension  which  has  followed  the  suspension 
of  only  a  few  moments;  but  I  have  found  that  there 
is  a  great  advantage  in  acute  cases,  in  frequently 
changing  the  spinal  jacket,  and  putting  it  on  each 
time  after  the  patient  has  been  hung  in  the  old  jacket 


—    128    — 

for  several  hours,  so  as  to  get  a  progressively  increased 
extension,  and  to  hold  such  extension  as  obtained. 

If  from  tenderness  of  the  projecting  vertebrae,  or 
from  the  presence  of  a  wound,  surgical  or  otherwise, 
it  is  desired  to  avoid  pressure  upon  the  vertebrae,  or 
to  have  access  to  the  affected  part,  all  that  is  neces- 
sary is,  to  cut  an  opening  in  the  jacket  immediately 
over  the  diseased  portion  of  the  body,  care  being 
taken  that  this  fenestrum  shall  not  be  so  large  as  to 
interfere  with  the  strength  of  the  jacket. 


CHAPTER  IV. 

THE    PERIPHERAL    NERVES. 

It  is  a  comparatively  rare  circumstance  for 
syphilis  directly  or  indirectly  to  affect  the  motor  or 
sensory  nerve  trunks,  but  nevertheless  such  implica- 
tion does  occur:  for  the  purposes  of  our  study,  the 
cases  may  very  natually  be  divided  into  three  sets. 
First,  Pressure  Neurites,  including  those  cases  in 
which  the  nerve  trunk  is  affected  simply  by  pressure, 
the  alterations  not  being  in  any  proper  sense  specific: 
Second,  Secondary  Syphilitic  Infiltration,  including 
those  cases  in  which  the  nerve  trunk  is  involved  in  a 
syphilitic  deposit  which  has  commenced  in  a  neighbor- 
ing organ,  and  has  secondarily  infiltrated  the  nerve  with 
gummatous  tissue:  Third,  Primary  Nerve- Syphilis, 
including  those  cases  in  which  the  lesion  is  distinctly 
specific  and  primary. 

Pressure  Neuritis.— A  syphilitic  neoplasm  if 
properly  placed,  is  of  course,  liable  to  produce  pres- 
sure upon  a  nerve  trunk,  which  pressure  leads  to 
irritation  and  then  to  inflammation,  and  finally  to  de- 
struction of  the  nerve  itself.  The  effects  of  such 
pressure  are  more  marked  where  the  gummatous 
tumor  is  so  situated  that  it  forces  the  nerve  against 
a  bone  or  other  hard  tissue.  That  these  secondary 
changes  may,  however,  occur  outside,  as  well  as  in- 
side,   the   cranium,    is  shown  by  a  case  reported  by 


—  i3°  — 
Zambaco,  in  which  the  syphilitic  tumor,  situated  in 
the  left  nates,  underneath  the  muscles,  compressed 
and  destroyed  the  sciatic  nerve.  In  any  such  case  the 
affected  nerve  is  found  either  slightly  reddened,  soft- 
ened, and  its  sheath  thickened,  or  it  may  be  smaller 
at  the  point  of  compression,  or  completely  atrophic 
and  reduced  to  a  thin  translucent  band. 

Secondary  Syphilitic  Infiltration. — A  contiguous 
gumma  may  so  encroach  upon  and  involve  a  nerve  as 
to  cause  a  secondary  infiltration  of  the  nerve  with 
syphilitic  cells.  Heubner  is  probably  correct  in  be- 
lieving that  this  is  only  possible  where  the  nerve  is 
not  surrounded  by  a  dense  sheath,  as  near  the  points 
of  the  origin  of  a  nerve,  and  especially  at  the  chiasm 
and  the  adjoining  parts  of  the  optic  nerves.  At  the 
latter  place,  not  very  rarely  a  tumor  extending  from  its 
starting  point  in  the  pia  mater  along  the  vessels  to 
the  chiasm,  forces  its  way  into  the  latter  so  that  it  be- 
comes impossible  to  draw  a  sharp  line  of  demarcation 
between  the  nerve  and  the  new  growth  of  the  pia  mater 
— the  whole  neighborhood  being  involved  in  a  gray- 
ish-red, gray,  or  yellowish-caseous,  material. 

Primary  Nerve  Syphilis. — There  are  two  distinct 
affections  of  the  nerve  trunks  which  require  to  be  con- 
sidered under  the  present  heading.  In  the  first  of 
these  it  still  remains  doubtful  whether  the  disease 
ought  really  to  be  considered  as  syphilitic;  while  in 
the  second  form,  the  presence  of  characteristic  gum- 
matous material  marks  with  certainity  the  nature  of 
the  lesion. 


—  I31  — 
I  have  occasionally  noted,  in  cases  in  which  there 
was  evident  specific  disease  of  the  nerve  centres, 
a  co-incident  tenderness  of  nerve  trunks  indicating 
that  the  latter  were  in  a  condition  of  inflammation, 
but  have  always  been  very  doubtful  as  to  whether  such 
neuritis  should  be  considered  as  due  directly  to  the 
specific  poison,  or  whether  it  was  simply  a  secondary 
inflammation  propagated  along  the  nerve  trunk  irri- 
tated by  a  gumma  somewhere  in  its  course.  A  case 
published  in  the  Wien.  Med.  Blatter  for  1886,  by  Dr. 
S.  Erhmann,  makes  it  probable,  however,  that  the 
syphilitic  poison  may  act  like  the  rheumatic,  the  alco- 
holic, the  plumbic,  and  kindred  poisons  in  producing 
wide  spread  polyneuritis.  A  man  thirty  years  old,  about 
nine  months  after  infection,  was  taken  with  paraesthe- 
sia,  pain  and  loss  of  power  affecting  the  left  forearm 
and  hand,  and  especially  marked  in  the  region  sup- 
plied by  the  ulnar  nerve,  and  not  apparent  in  the  ter- 
ritory of  the  radial.  The  ulnar  nerve  was  exceedingly 
sensitive  to  pressure;  the  median  nerve  much  less 
sensitive,  but  still  much  more  so  than  normal;  and  the 
radial  was  entirely  free  from  tenderness.  The  elec- 
trical excitability  of  the  ulnar  and  median  nerves  was 
distinctly  altered,  and  there  was  wasting  of  the  mus- 
cles, disturbance  of  the  sensibility  of  the  skin,  and  of 
the  vaso-motor  system  in  the  tributary  territory.  Later 
in  the  attacks,  the  nerves  of  the  leg  became  tender, 
although  there  were  never  any  very  pronounced  par- 
alytic or  pain  phenomena,  and  there  were  no  indications 


—  J32  — 
of  disease  of  the  nerve  centres.     Under   active  syphi- 
litic treatment  with  the  iodide,  and  local  measures,  a 
cure  was  obtained. 

The  case  reported  by  Ehrmann  has  no  exact 
parallel  that  I  know  of  in  medical  literature,  although 
a  collection  of  somewhat  similar  instances  is  given  by 
Erhmann  at  the  conclusion  of  his  article.  All  of  these 
cases,  however,  are  open  to  grave  objections,  and  we 
must  still  consider  it  somewhat  doubtful  whether 
syphilis  can  produce  an  acute  multiple  neuritis. 

Primary  gummatous  syphilis  of  those  portions  of 
the  peripheral  nerves  which  are  situated  outside  of 
the  bony  envelopes,  is  excessively  rare.  I  have  never 
seen  such  a  case,  and,  at  present  writing,  can  only 
refer  to  the  one  reported  by  Esmarch  and  Jessen 
(quoted  by  Heubner),  in  which  the  right  oculo-motor 
nerve  was  degenerated  externally  to  the  skull,  while 
the  left  oculo-motor  was  similarly  affected  within  the 
cranial  cavity.  The  nerve-roots,  or  the  nerve-trunks, 
within  the  bony  envelopes,  are  more  frequently  at- 
tacked; they  may  be  the  seat  of  numerous  minute 
gummatous  tumors,  or  of  an  isolated  gummatous 
growth;  commonly,  but  not  always,  in  the  great  ma- 
jority of  these  cases  larger  gummatous  can  be  found 
in  the  neighboring  nerve  centres. 

According  to  the  research  of  Prof.  O.  Kahler 
(Zeitschrift  fur  Heilkunde,  1887),  the  gumma  appears 
always  to  spring  from  the  minute  vessels  which  supply 
the  nerve,  an  origin  which  is  confirmed  by  our  knowl- 
edge of  syphilis  of  the  nerve  centres. 


—    133   — 

The  first  change  is  an  infiltration  of  the  wall  and 
immediate  neighborhood  of  the  vessel,  with  minute 
cells.  As  the  process  continues,  the  vessels  become 
more  and  more  enlarged  and  tortuous,  and  the  infil- 
tration forces  itself  away  through  the  trabecule  of  the 
nerve  whilst  the  nerve-bundles  themselves  gradually 
disappear,  and  often  can  be  seen  in  various  parts  of 
the  preparation  undergoing  degeneration.  When  the 
process  is  complete,  the  blood  vessels  themselves  have 
been  destroyed,  and  the  position  of  the  obliterated 
arteries  will  be  seen,  in  the  syphilitic  product,  occupied 
by  spindle-form  cells  and  the  evidences  of  fibroid 
structure.  The  epineurima,  or  sheath  of  the  nerve, 
is  usually  distended  or  spread  out  over  the  growth, 
but  very  rarely  is  it  completely  destroyed. 

The  symptoms  which  are  produced  by  nerve- 
gumma,  are  almost  always  intermingled  with  those 
which  are  due  to  implication  of  the  nerve  centres, 
since  it  is  extremely  rare  for  nerve  gumma  to  exist 
as  an  early  single  lesion.  As  has  been  stated  in  the 
chapter  upon  spinal  syphilis,  pain,  spasm,  and  perhaps 
even  paraplegia,  are  not  infrequently  the  outcome 
of  disease  of  the  nerve  roots,  rather  than  of  the 
cord  itself;  but  it  is  very  unusual  for  the  disease 
of  the  nerve  roots  to  go  so  far  as  to  entirely  abol- 
ish their  functions.  Thus,  pain  of  a  most  atrocious 
character  following  the  distribution  of  the  nerve 
trunks,  is  much  more  frequently  seen,  than  is  anaes- 
thesia; and  very  infrequently  does  a  motor  nerve  have 


—  134  — 
its  power  so  absolutely  destroyed  that  the  muscle  sup- 
plied by   it  wastes  decidedly,  or  offers  the  electrical 
reaction  of  degeneration. 

The  typical  headache  of  cerebral  syphilis  is  not 
due  to  an  immediate,  direct,  syphilitic  alteration  of  the 
trigeminal  nerve;  for  when  a  gumma  directly  attacks 
this  nerve,  agonizing  pains,  which  are  shooting,  dart- 
ing, resembling  those  commonly  spoken  of  as  neural- 
gic, replace  the  characteristic  headache  of  cerebral 
syphilis.  I  have  seen  the  most  frightful  tic  douleureux 
involving  the  whole  external  distribution  of  the  tri- 
geminal nerves,  and  in  some  of  its  explosions  accom- 
panied by  facial  contortions,  as  an  early  manifestation 
of  intra-cranial  syphilis,  of  which  the  only  other  symp- 
toms were  failure  of  health  and  of  intellectual  activity 
— a  failure  which  might  well  have  been  ascribed, 
and  may  really  have  been  due,  to  the  excessive  pain 
and  loss  of  rest.  The  true  nature  of  such  a  case  as 
this  is  liable  to  be  overlooked.  There  is,  however, 
almost  invariably,  a  peculiar  indefiniteness  of  the 
symptoms — some  little  departure  from  the  ordinary 
type  of  a  tic  douleureux — which  ought  to  arrest  the 
attention  of  the  practitioner.  In  the  case  under  my 
care  just  alluded  to,  such  indefiniteness  or  atypical 
character  of  the  symptoms,  led  to  an  examination  of 
the  person  of  the  patient,  and  the  finding  of  distinct 
signs  of  previous  syphilis,  which  in  turn  caused  the 
exhibition  of  antisyphilitic  remedies  with  the  result  of 
complete  recovery. 


—  i35  — 
The  treatment  of  syphilis   of  a  nerve  does  not 
differ  from  that  of  specific  disease  of  a  nerve  centre, 
and  therefore  does  not  seem  to  require  further  discus- 
sion. 


SUGGESTIONS  FOR  PRESCRIPTIONS 


Cocaine  Tablets. 


Chloranodyne 

and 

Coto  Bark. 


Pepsinuni  Purum 

Tablets, 
Sugar-Coated,  1  gr. 


Glycerin 
Suppositories. 
95%  Glycerin. 


TF  you  use  Cocaine  you  must  know  the  advantage  of  being 
-*-  able  to  prepare  readily  a  fresh  solution  of  any  desired 
strength.  This  can  be  done  instantaneously  by  our  soluble 
Cocaine  Muriate  Tablets,  2*4  and  1%  grains,  put  up  in  vials  of 
12  and  bottles  of  100,  with  directions  as  to  how  many  tablets 
to  use  in  making  solutions  of  desired  strength.  You  will  find 
them  very  convenient. 

^rOU  no  doubt  employ,  when  indicated  in  summer  diar- 
-*-  rhcea,  anodynes  and  astringents.  We  would  commend 
to  you  for  trial  two  eligible  ones  which  we  make,  and  which 
have  been  used  with  much  success.  "We  refer  to  Chlorano- 
dyne, an  efficient  combination  of  anodynes  and  antispasmod- 
ics, and  fluid  extract  Coto  Bark,  the  valuable  astringent 
properties  of  which  render  it  of  great  service  in  restoring 
tone  to  the  relaxed  mucous  membrane,  and  in  checking  the 
excessive  discharge. 

rpHESE  Tablets  afford  a  very  convenient  and  ready  method 
J-  for  the  administration  of  Pepsin.  In  this  form  Pepsin 
suffers  no  loss  in  peptic  or  digestive  power  with  an  insoluble 
salt  of  bismuth,  such  as  the  subnitrate.  When  combined 
with  bismuth  and  ammonium  citrate,  in  mildly  alkaline  solu- 
tions, the  activity  of  the  Pepsin  is  entirely  destroyed,  and 
acidification  fails  to  restore  its  lost  energy. 

THIS  ready  means  of  securing  defecation  is  likely  to  become 
very  popular.  It  is  a  great  improvement  over  the  injec- 
tion of  the  glycerin,  and  quite  as  efficacious.  To  those 
physicians  who  have  not  employed  them,  we  commend  their 
early  trial,  and  to  this  end  we  will  furnish  samples  free  on 
request.  In  prescribing  we  ask  physicians  who  desire  to  use 
a  reliable,  active  product,  to  specify  glycerin  suppositories  of 
our  manufacture. 


PARKE,    DAVIS    &    CO., 

Manufacturing  Chemists.  DETROIT   AND    NEW  YORK. 


IN    EXPLANATION 


oar 


Tie  Physicians'  Leisure  Library. 


We  have  made  a  new  departure  in  the  publication  of  medical  books.  As  you  no 
doubt  know,  many  of  the  large  treatises  published,  which  sell  for  four  or  five  dollars, 
contain  much  irrelevant  matter  of  no  practical  value  to  the  physician,  and  their  high 
price  makes  it  often  impossible  for  the  average  practitioner  to  purchase  anything 
like  a  complete  library. 

Believing  that  short  practical  treatises,  prepared  by  well-known  authors,  con- 
taining the  gist  of  what  they  had  to  say  regarding  the  treatment  of  diseases  com- 
monly met  with,  and  which  they  had  made  a  special  study  of,  sold  at  a  small  price, 
would  be  welcomed  by  the  majority  of  the  profession,  we  have  arranged  for  the 
publication  of  such  a  series,  calling  it  The  Physicians'  Leisure  Library. 

This  series  has  met  with  the  approval  and  appreciation  of  the  medical  profes- 
sion, and  we  shall  continue  to  issue  in  it  books  by  eminent  authors  of  this  country 
and  Europe,  covering  the  best  modern  treatment  of  prevalent  diseases. 

The  series  will  certainly  afford  practitioners  and  students  an  opportunity  never 
before  presented  for  obtaining  a  working  library  of  books  by  the  best  authors  at  a 
price  which  places  them  within  the  reach  of  all.  The  books  are  amply  illustrated, 
and  issued  in  attractive  form. 

They  may  be  had  bound  either  in  durable  paper  covers  at  25  Cts.  per  copy, 
or  in  cloth  at  50  Cts.  per  copy.  Complete  series  of  12  books  in  sets  as  announced, 
at  $2.50,  in  paper,  or  cloth  at  $5.00,  postage  prepaid. 


PHYSICIANS'  LEISURE  LIBRARY 


PRICE 


PAPER,  25  CTS.  PER  COPY,  $2.50  PER  SET }  CLOTH,  50  CTS  PER  COPY, 
$5.00  PER  SET. 


SERIES  I. 


Inhalers,  Inhalations  and  Inhalants. 
By  Beverley  Robin&on,  M.  D. 

The  Use  of  Electricity  in  the  Removal  of 
Superfluous  Hair  and  the  Treatment  of 
Various  Facial  Blemishes. 
By  Geo.  Henry  Fox,  M.  D. 

New  Medications. 

By  Dujardin-Beaumetz,  M.  D. 

The  Modern  Treatment  of  Ear  Diseases. 
By  Samuel  Sexton,  M.  D. 

Spinal  Irritation. 

By  William  A   Hammond,  M.  D. 

The  Modern  Treatment  of  Eczema. 
By  Henry  G.  Piffard,  M.  D. 


Antiseptic  Midwifery. 

By  Henry  J.  Garrigues,  M.  D. 
On  the  Determination  of  the  Necessityfcr 
Wearing  Glasses. 

By  JL>.  B.  St.  John  Roosa,  M.  D. 

The  Physiological, Pathological  and  Ther- 
apeutic Effects  of  Compressed  Air. 
By  Andrew  H.  Smith,  M.  D. 

GranularLids  and  ContagiousOPhthalmia. 

By  W.  F.  Mittendorf,  M.  D. 
Practical  Bacteriology. 

By  Thomas  E.  Saiterthwaile,  M.  D. 
Pregnancy,    Parturition,    the     Puerperal 
State  and  their  Complications. 

By  Paul  F.  Munde.  M.  D. 


SERIES  II. 


The  Diagnosisand  Treatmentof  Haemor- 
rhoids. 

By  Chas.  B.  Kelsey,  M.  D. 

Oiseases  of  the  Heart.    Vol.  1. 

By  Dujardin-Beaumetz,  M.  D. 

Diseasesof  the  Heart.    Vol.  II. 
By  Dujardin-Beaumetz,  M.  D 

The  Modern  Treatmentof  Diarrhoea  and 

yBynA^B.   Palmer,  M.   D. 
Intestinal  Diseases  of  Children, 
By  A.  Jacobi,  M.  D. 


The  Modern  Treatment  of  Headaches. 
By  Allan  McLane  Hamilton,  M.  D. 

The  Modern  Treatment  of  Pleurisy  and 
Pneumonia. 

By  G,  M.  Garland,  M.  D. 
How  to  Use  the  Laryngoscope. 

By  J.  Solis  Cohln7iVl.  D. 
Diseasesof  the  Male  Urethra. 

By  Kessenden  N.  Otis,  M.  D. 
The  Disorders  of  Menstruation. 

By  Edward  W.  Jenks,  M.  D. 
The  Infectious  Diseases.  In 2  vote. 

By  Karl   Liebermeister. 


SERIES  III. 


Abdominal  Surgery 

By  Hal  C.  Wyman,  M,  D. 

Diseasesof  the  Liver. 

By  Dujardin-Beaumetz,  M.D. 

Hysteria  and  Epilepsy.    .        ,,   ^ 
By  J.  Leonard  Corning-,  M.  D. 

Diseases  of  the  Kidney.  ,  _ 

By  Dujardin-Beaumetz,  M.  D. 

The  Theory  and  Practice  of  the  Ophthal- 
moscope. 

By  J.  Herbert  Claiborne,  Jr.,  M.  D. 
Modern  Treatment  of  Bright's  Disease. 

By  Alfred  L.   Loomis,   M.  D. 

Clinical  Lectures  on  Certain  Diseases  of 
Nervous  System. 

By  Prof.  J.  M.  Charcot,  M.  D. 


\    The  Radical  Cure  of  Hernia. 

By  Henry  O.  Marcy,  A.  M.,  M.  D., 
L.  L.  D. 

i    The  Treatment  of  Diseases  of  the  Blad- 
der, Prostate  and  Urethra. 
By  H.  O.  Walker,  M.  D. 

!    Dyspepsia. 

3    Hy  Frank  Woodbury,  M.  D. 

|    The  Treatment  of  the  Morphia  Habit. 
By  Erlenmeyer. 

The  Etiologly,  Diagnosisand  Therapy  of 
Tuberculosis. 
J  By  Frof.  H.  von  Ziemssen. 


SERIES  IV. 


Nervous  Syphilis. 

By  H.  C.  Wood,  M.  D. 

Education  and   Culture  as  correlated  to 
the  Health  and  Diseases  of  Women. 
By  J.  A.  C.  Skene,  M.  D. 

Diabetes. 

By  A.  H  Smith,  M.  D 

Rheumatism  and  Gout.  ^ 

By  F.  Leroy  Satterlee,  M.  D. 

Hypodermic  Medication. 

By  Bourneville  and  Bricon. 

A  Treatise  on  Fractures. 

By  Armand  Despris,  M.  D. 


Neuralgia. 

BySE.  P.  Hurd,  M.  D. 
Auscultation  and  Percussion. 

By  Frederick  C.  Shattuck,  M.  D. 

Practical  Points  in  the   Management  of 
Diseases  of  Children. 
By  I.  N   Love,  M.  D. 

Electricity   its  application  in  Medicine, 
By  Wellington  Adams,  M.  D. 

Taking  Cold. 

By  F.  H.  Bosworth,  M.  D. 

Some    Minor  and    Major   Fallacies  con- 
cerning Syphilis. 

By  E.  L.  Keyes,  M.  D. 


GEORGE  S.  DAVIS,  Publisher, 

3P.  O.  Boas  -irro.  Detroit,    Ifc^iclx. 


DATE  DUE 

OCT 

I  9  2002 

-NOV  19J 

nn? 

i 

. 

i 

DEMCO  38-296 

